spring 2009 Volume 2009, Number 2
The Impact of Economics on Private Practice Physicians Finding New Value in Your Medical Practice Tourist Season: Are Patients
Traveling Abroad for Discounted Care?
at what cost?
Responding to the Economic Slide
Perspectives: Physicians Answer
How the Economy Has Impacted Their Practice
The Road Less Traveled: Carl L. Brumback, MD Sp e c i a l RE P ORT :
The Economic impact of private practice Physicians in florida SSOCIAT
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There are many great reasons to attend our annual meeting. Admittedly, a few of them have nothing to do with medicine.
join us July 24 - 26, 2009, at the Boca Raton Resort & Club
Annual Meeting
• Participate in a wide selection of CME seminars • Visit over 100 vendors at the Florida Medical Expo • Attend the meeting of the House of Delegates and • Enjoy the traditional south Florida experience For more information, visit www.fmaonline.org/am2009 or call 800.762.0233.
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spring 2009
contents It Ain’t Over ‘til It’s Over
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If you think you are out of the woods with malpractice claims after two years and a day from the matter in question, think again. In this article, defense attorney Tom Dukes, Esq., reveals an up-close look at the reality of the statute of limitations, and the many misconceptions that surrounds it. Learn more about this complicated window for litigation, the difficulty in determining when it has opened and whether or not it ever truly closes.
At What Cost? 16
No one is immune from the current economic decline, including physicians and their patients. As people continue to spend more carefully, vital procedures and medications are often overlooked in order to save money. Further, a growing number of patients have begun comparison-shopping, drawing physicians into direct competition. Take a closer look at the how the economy is affecting health care and learn how some physicians are beginning to adapt.
Finding New Value in Your Medical Practice
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All over the world, business as usual has quickly become a thing of the past. For many medical practices, retaining viability in these challenging economic times will require a new way of thinking and performing. For proactive and open-minded physicians, new value may be found in even the most successful medical practice. Find out what cutting-edge practices are doing to maximize their potential and profitability.
Tourist season:
Are Patients Traveling Abroad for Discounted Care?
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As the world continues to shrink, the markets for many industries have become increasingly global. Medicine is no exception. As more opportunities to receive medical treatment abroad become available, physicians and other medical professionals are finding new and innovative ways to maintain the United States’ role as the world’s leading medical destination. In this article you will learn more about medical tourism and the unique role Florida plays in this burgeoning industry.
The Road Less Traveled: Carl L. Brumback, MD
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When Carl L. Brumback, MD, landed in Palm Beach County, he resolved to “tackle every conceivable health problem and develop the resources to do so.” Now, decades later, the entire country continues to benefit from his remarkable efforts. Take a closer look at this great physician who committed his life and career to taking the road less traveled.
Physician to Physician
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We asked four Florida physicians one simple question: “What impact has the recent economic decline had on your medical practice?”
President’s letter
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Executive vice president’s letter
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This card can save your life:
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Letter from the FMA Alliance
Special Report: The Economic Impact of Private Practice Physicians’ Offices in Florida (Starts on Back Cover) www.fmaonline.org
Editor’s letter
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Board of Governors Ralph J. Nobo, Jr., MD District E
Ashley E. Booth, MD Young Physician Section
James B. Dolan, MD President-Elect
Nabil A. El Sanadi, MD District F
Joel R. Judah, MD Resident and Fellow Section
Madelyn E. Butler, MD Vice President
Stephan Baker, MD District G
Jeremy L. Tharp Medical Student Section
Vincent A. DeGennaro, MD Secretary
Silvio A. Garcia, MD At Large
Diane R. Andrews, PhD, RN FMA Alliance
W. Alan Harmon, MD Treasurer
Neal P. Dunn, MD At Large
Donald F. Foy, Sr. Public Member
Lisa A. Cosgrove, MD Primary Care Specialties
Karen Wendland, MS Council of Medical Society Executives
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Alan B. Pillersdorf, MD Speaker
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Steven R. West, MD President
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David J. Becker, MD Vice Speaker
Linda S. Cox, MD Medical Specialties
Karl M. Altenburger, MD Immediate Past President
Alan S. Routman, MD Surgical Specialties
John N. Katopodis, MD District A
Miguel A. Machado, MD Council on Legislation
Eli N. Lerner, MD District B
E. Coy Irvin, MD AMA Delegation
David M. McKalip, MD District C
James H. Rubenstein, MD FMA PAC
Harold L. Greenberg, MD District D
M. Kamel H. Elzawahry, MD Specialty Society Section
Editorial Staff Editor-In-Chief Marc J. Yacht, MD, MPH
Helping Physic
Ana Viamonte Ros, MD, MPH State Surgeon General
Associate Editors Karl M. Altenburger, MD Thomas L. Hicks, MD
Managing Editor Lynne Takacs Publication Design Michael Calienes michaelc@transplant-1.com
Robert E. Cline, MD State Board of Medicine
Staff Writer John Tyler
Timothy J. Stapleton Executive Vice President
Advertising Shawn Winship To learn more about advertising in Florida Medical Magazine, contact Shawn Winship at swinship @ medone.org, 1-800-762-0233, or visit www.fmaonline.org/RateCard.pdf
spring 2009 (Volume 2009, Number 2)
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Application to Mail at Periodicals Postage Prices is Pending at Tallahassee, FL. POSTMASTER: Send changes to: FLORIDA MEDICAL MAGAZINE 123 South Adams Street Tallahassee, FL 32301-7719
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Copyright 2009 by Florida Medical Association, Inc. All rights reserved. Views expressed in this issue represent those of the individual authors and may not represent the views of the Florida Medical Association, Inc. The Florida Medical Association, Inc., does not represent the accuracy or reliability of any of the advertisers displayed in this publication and does not necessarily endorse any of the advertisers in this publication.
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FLORIDA MEDICAL MAGAZINE is published four times a year (February, May, August and November) by the Florida Medical Association, Inc., located at 123 South Adams Street, Tallahassee, FL, 32301-7719.
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Visit www.fmaonline.org for more information and updates or call 800.762.0233.
Correction : Please note that the chart on page 47 of our Spring issue was misprinted. Please download the corrected chart at http://www.fmaonline.org/informz/Table1.pdf
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Florida Medical Magazine winter 2009
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Looking Ahead As physicians
we understand that few things in life are certain. Look no further than our current economy. Many things that will
impact our lives and the lives of our patients have yet to be determined. Yet discussions in Washington have begun and decisions soon will be made – the future of American health care remains at the forefront.
Nearly five months into a new presidential administration, we all have been given a glimpse of where health care may be heading. Whatever our political beliefs, we can all agree on one thing – access to care is of the utmost concern. The United States government, in cooperation with national health care organizations like the American Medical Association (AMA), is working hard to reform health care. Given this daunting challenge, I believe it is important to understand the system we have today before we begin to build the system of tomorrow. We all have heard the numbers: 47 million Americans are without health insurance. The World Health Organization (WHO) ranks our health system as number 37 in the world. In past editions of my President’s Weekly Report1, I have explored the truth behind these misleading numbers. Although our health care system has flaws, it remains the very best system in terms of excellence and innovation. National health care reform, if it is to succeed, cannot jeopardize or diminish either of these fundamental qualities. The Florida Medical Association (FMA) believes an effective health care system will address five key features. These are reflected in the FMA Prescription for Health Care Reform2, which I presented with other FMA leadership in March to the Florida Congressional delegation. As the new administration pursues national health care reform, the FMA will continue to advocate on behalf of Florida’s physicians and their patients. The road ahead certainly is long and full of obstacles and uncertainties that will test our mettle. Yet, with each day the resolve of Florida’s physicians grows stronger. We have an opportunity to enhance the American health care system for the benefit of all. Remaining true to our principles, we can find innovative solutions and increase access to the highest quality care in the world. As we endure the current economic drought, let us not forget how much we all have to look forward to. Sincerely,
Steven R. West, MD FMA President 1 You can access archived editions of the FMA President’s Weekly Reports at http://www.fmaonline.org/pages/news/pwr.html 2 The FMA Prescription for Health Care Reform can be accessed at http://www.fmaonline.org/pages/govtaffairs/files/FMAReform4-1.pdf
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five fundamental qualities of National Health Care Reform
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Accessibility
When needed, a system of quality hospitals, medical practices, and related services must be available, sustainable, and accessible. The latest technology, modern medication, and treatments, as well as primary care physicians and super specialists, must be developed and maintained well in advance of one’s illness.
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Patients must be able to obtain the care they require at a cost that makes sense. Third parties must avoid imposing costly mandates and administrative costs that draw precious resources away from direct patient care.
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Patients once again must be the focus of our health care system. Physicians and hospitals exist to serve patients in their time of need and should be primarily accountable to patients, not to the government or other third parties.
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Fraud and abuse in the health care system harm all of us and must be stopped. Sadly, many government systems and solutions often make the problem worse. Government regulations must be judicious, and elected officials should be held accountable for failures.
Affordability
Choice
Fraud Prevention
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Public Safety Net
www.fmaonline.org
In the private sector, quality health care services must be offered at an affordable price that the patient is willing to pay. Those who need assistance should be cared for by a reliable public safety net. Consumers should control prices as well as quality.
Florida Medical Magazine winter 2009
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Executive Vice President’s Letter by Timothy J. Stapleton For many months now, the economy has struggled. As a result, we have all been forced to reevaluate our finances and take a closer look at how business is conducted in this country. As policymakers at the state and federal level work to address the economic issues facing our country, health care reform hangs in the balance. It has long been our contention that physicians have a positive impact on the economy and should be treated as a valuable resource. In order to help us make our case with legislators at the state and federal level, the Florida Medical Association (FMA) conducted a study on the economic impact of private practice physicians in Florida, which you will find at the back of this edition of Florida Medical Magazine. This study, completed in partnership with the Florida State University Center for Economic Forecasting and Analysis, provides an indepth look at the contributions of private practice physicians to Florida’s state and local economies. What we found is not surprising. The private practice of medicine is an economic engine, creating employment opportunities within health care and other sectors, purchasing a wide variety of goods and services from local businesses, and generating a considerable amount of tax revenue to state and local governments.
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In fact, the FMA/FSU study found that in 2009, Florida’s private medical offices will support approximately 451,500 jobs and generate $22 billion in personal income. These jobs represent a striking five percent of total state employment. Further, private medical offices generate an estimated $56 billion in total economic activity and $3 billion in government revenues. Ultimately, the data suggests that each individual private practice physician in Florida today supports an average of 19 additional jobs, $913,000 in personal income, and $2.3 million in total economic activity.
almost 650,000 jobs, $41 billion in personal income, $93 billion in total economic activity, and $6 billion in government revenues per year. Unfortunately, these numbers do not account for Florida’s current and increasing physician shortage. The FMA study demonstrates the need to improve Florida’s environment for practicing medicine, not only to increase access to care, but also to fortify our economy. Increasing Florida’s ratio of physicians per population to meet the national average by 2012 would create an additional 50,000 jobs, bringing with it $3.6 billion in personal income, and $6.5 billion in greater total economic activity. Likewise, expanding Florida’s ratio of graduate medical education positions to meet the national average by 2012 would create an additional 34,000 jobs, bringing with it $2.4 billion in personal income, and $4.3 billion in total economic activity.
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As health care reform discussions continue among our policymakers, this study will make a powerful argument that the economic impact of Florida’s physicians cannot be underestimated or ignored. The study further addresses the many factors that influence Florida’s physicians in terms of the decision to remain in practice. Addressing these policies and regulations will make a significant difference to physicians and Floridians alike. I look forward to seeing the impact of this study in the months and years to come.
By 2020, the annual economic impact of physicians on Florida’s economy is expected to increase dramatically to Sincerely,
Timothy J. Stapleton FMA Executive Vice President
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www.fmaonline.org
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Florida Medical Magazine winter 2009
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This card can save your life
by Diane R. Andrews, PhD, RN FMA Alliance President
It can be scary
as a patient, to be rushed to the Emergency Room (ER). It can be even scarier if one happens to be unresponsive and dependent on the medical staff to know all about one’s medications, allergies, and anything else that might interfere with emergency treatment.
From a physician’s perspective, it would be so much easier if all patients entered the ER (or any medical office for that matter) with a list of instructions. Knowing immediately what a patient’s perscriptions are can expedite treatment, reduce office time, and in some cases, save lives. The FMA Alliance (FMAA) has a remedy for physicians and patients alike. The Medi-File card was created for patients who take one or more medications. This card is a helpful tool and reference guide that can be kept in one’s wallet at all times. In case of an emergency, and for routine medical appointments, this card can be an important and even lifesaving reference for ongoing or immediate treatment.
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Florida Medical Magazine winter 2009
As you might imagine, Medi-File cards are especially beneficial to senior patients and can become invaluable during emergency situations. It may come as no surprise that the number of geriatric patients treated in emergency rooms is likely to increase dramatically over the next 15 to 20 years. Presently, seniors represent approximately 15 percent of all emergency patients and even the most conservative estimates reach 28 percent by 2025. Various experts, however, believe that this number will rise to at least one-third of all patients nationwide and closer to 40 percent in rural and many suburban areas. In Florida, these numbers already exceed 60 percent1.
www.fmaonline.org
Based on these statistics, Medi-File cards can be an asset to patients and physicians alike by expediting the emergency room process. The card provides physicians with the benefit of knowing exactly what will improve or hinder a patient’s progress. Geriatric patients, equipped with Medi-File cards, can remain confident in knowing that they will receive the appropriate care to meet their individual needs.
Today, over 25 prescriptions were filled for patients of Dr. Peter Williams.
“Medi-File cards originally were developed with doctors’ offices in mind,” says Elaine Hale, FMAA Immediate Past President. The cards were made available to physicians as a patient education tool, but over time, the target demographic has grown considerably. The Orange County Medical Society Alliance distributes these cards to homeless shelters, senior programs, retirement homes, and doctors’ offices.
Problem is, he only wrote 10 of them.
Palm Beach County Medical Society Alliance (PBCMSA) members distribute Medi-File cards to nursing homes, adult care facilities, rehabilitation facilities, condiminiums, and physician offices. “Facilities that were given the cards have requested additional cards and are very appreciative of the donation,” says Mary Jo Higgins, President of PBCMSA. Over the past three years, PBCMSA has distributed more than 2,000 cards.
And while you may think your current
The FMA Alliance Medi-File card is available to all FMA and Alliance members. The card comes in packs of 250 and can be mailed to physician offices for patient distribution. Contact the FMA Alliance office at 800.762.0233 or email alliance@medone.org to receive your Medi-File cards. Medi-File cards are just one more way in which the FMA Alliance is making a difference.
and serious liability by purchasing the
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1. American College of Emergency Physicians Report on The Future of Geriatric Care in our Nation’s Emergency Departments: Impact and Implications. www.acep.org/workarea/showcontent. aspx?id=43376
www.fmaonline.org
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The Unique History of Public Health in Florida by Marc J. Yacht, MD, MPH
of Dr. Carl Brumback in the current issue
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The Profile
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Editor-in-Chief
allows reflection on the proud history of
Florida’s public health system. Add the late Dr. Wilson T. Sowder, and you have two
D
giants who modernized and propelled our Florida public health system into one of with significant detours along the way.
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One cannot ignore the efforts of the Florida Medical Association (FMA) and particularly one of its executives, Mr. E. Russell Jackson, Jr., for battling and creating an appropriate spotlight for a needed Florida Public Health Department. For almost three decades, Russ pursued the reinstitution of the Florida Board of Health and a new Department of Health. The Board of Health was abolished in 1969 and relegated to a division with county health units, becoming a part of the Florida Department of Health and Rehabilitative Services. Russ left his position in the new Division of Health and began his unique efforts. Russ’s efforts were realized in 1997 with the establishment of the new Department of Health. The late Dr. Alvin Smith, then FMA President, convinced a concerned Governor Lawton Chiles, that a Department of Health was good for Florida. Dr. Smith’s invaluable role in the successful establishment of the new department cannot be overstated, as Chiles was set to veto the bill. Once established, the newly appointed Secretary, Dr. James Howell, another major figure in Florida’s public health history, brought the new train out of the station. Yellow fever, cholera, dengue fever, malaria, and smallpox triggered the birth of Florida’s public health system in 1889. Diseases were unchecked and rampant. People fled Jacksonville to escape yellow fever. Political
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the nation’s best. The path to our current department was fought long and hard,
Florida Medical Magazine winter 2009
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leadership realized that poor sanitation, lethal epidemics, and the resulting loss of life were undermining the state’s growth. A Board of Health was established, as was the beginning of Florida’s public health system, led by a colorful physician, Dr. Joseph Yates Porter. An experienced doctor who had fought the dreaded yellow fever in Key West, Porter began a relentless battle against Florida’s infectious scourges. Porter’s and others’ efforts brought yellow fever under control at the turn of the century. Other diseases such as dengue fever and cholera persisted. Weapons against disease included fumigation and quarantine. Identifying mosquitoes as the vector of yellow fever resulted in mosquito control efforts. The need to track case numbers resulted in the establishment of vital statistics, disease reporting, and investigation. Laboratory services came about at the turn of the century. By 1914, three nurses were hired to care for tuberculosis patients.
In 1922, the county health units were established as were the maternal and infant health program. The hiring of public health nurses in regional offices ultimately expanded maternal and child health services to include venereal disease services and
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P g n i p l e H sanitation services. The Works Progress Administration projects during the Roosevelt era expanded efforts to dredge swamps and marshes for mosquito control. The final pieces of the public health puzzle were in place in the 1940s with sanitary codes, sanitary engineers, and sanitarians. Initially, their efforts focused on sewage treatment and water systems, but ultimately would include food service regulation. In 1948 the Division of Veterinary Public Health directed efforts toward rabies vaccination and control, as well as zoonotic diseases.
Today’s typical health department has a multimillion dollar budget. Sixty-seven county health departments integrate well with other human service agencies and the private sector within constituent communities. Practicing Florida physicians and the FMA have a long history of support for Florida’s public health efforts.
i c i s hy
As Florida’s health priorities have changed, so has Florida’s public health system. Although infectious disease, sanitation, vital statistics, and maternal and child health remain cornerstones of public health practice, chronic disease, women infants and children, prenatal care, primary care, and bio-terrorism responsibilities have been added as new and emerging public health services in Florida communities. Whenever support wanes for public health, important new challenges such as bird flu, SARS, West Nile Virus, food-related outbreaks, and hurricanes remind Florida’s leaders of the importance of a strong and well-funded public health effort.
Florida’s public health history and progress is intertwined with the FMA’s growth, and together have had an enormous impact in keeping Florida citizens and visitors healthy. Both histories are colorful, productive, and essential for Florida’s continued growth and progress.
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’ It Ain t ‘til it’s over
A Physician’s Primer on the Statute of Limitations
As a medical malpractice defense lawyer, one of the first questions I am asked by a physician worried about a claim is when the statute of limitations runs. Many physicians have heard that the statute of limitations – the time in which someone can bring a claim – is two years. Accordingly, they assume that, two years and one day following an adverse event, they are out of the woods. Unfortunately, this is not the law. Florida Statute 95.11 does indeed define the period of limitations as two years. However, it is two years from the time a reasonable person knew or should have known of the possibility of medical negligence. This timeframe frequently is very hard to determine. Much of the time it is up to a jury to decide, leaving no practical benefit to a physician. Common sense tells us that, if a jury is faced with a close question and thinks that a physician is responsible for wrongdoing, the physician will not escape on a “technicality” like the statute of limitations. Of course, a statute of limitations defense certainly is not a technicality. It is a public policy judgment that is present in virtually every type of litigation. It provides finality, allows for a reasonable defense by assuring some chance that people will remember important events, and brings stability to our civil justice system. Be that as it may, you get the picture – if a statute of limitations question goes to the jury, chances are it is probably going to be a tough sell for the defense. Frequently, when the statute of limitations commences is hard to determine before a lawsuit actually is filed. In Florida, we have presuit screening in malpractice cases
that is designed to weed out frivolous claims. However, information gleaned in presuit cannot be used once a lawsuit commences. It is privileged information and must be recreated in the subsequent lawsuit. Likewise, interviews done in presuit, called “unsworn statements,” is available to both sides of a potential lawsuit and cannot be used for any purpose if there is subsequent litigation. Thus, establishing in presuit when someone knew or should have known of the possibility of negligence may not provide the final word. Even once the lawsuit commences, it often is difficult to determine when the statute of limitations begins to run. If the alleged negligence is obvious – for example, if the surgeon cuts off the wrong leg – the statute of limitations will begin to run at the time of the event. However, these cases are relatively rare. Likewise, if a physician admits negligence and documents it in the record, one might say that the statue begins to run at that point in time. However, the patient certainly could deny that the physician specifically admitted wrongdoing, possibly postponing the time that the statute of limitations begins to run. Furthermore, even if a surgeon discusses a bad surgical outcome with a patient – for example, if the surgeon takes the position
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t over that the outcome was a complication of the procedure and did not result from negligence – that will not necessarily trigger the start of the statute of limitations.
In a cancer misdiagnosis case, for example, when a chest x-ray allegedly is read incorrectly, the statute of limitations does not begin, at least, until the patient knows of the original potential misdiagnosis. It may not even commence at that point in time if the original misdiagnosis is attributed by health care providers to factors other than negligence. Likewise, the statute of limitations will not begin to run on an incapacitated person (for example, someone who is injured by a stroke and is neurologically profoundly impaired) until a guardian is appointed for that person, which may be well after the adverse event. There is an outer limit to the time that a physician is exposed in malpractice. As we discussed, Florida’s statute of limitations, Fla. Stat. 95.11(4)(b), establishes two years from the time from when one knew or should have known of the possibility of malpractice within which one can bring a claim. The statute of repose, also found in Fla. Stat. 95.11(4)(b) cuts off a cause of action at a finite time, even if it has not yet accrued under the statue of limitations. Four years after an event, unless there is fraud, the statute of repose will eliminate any potential claim, even if the patient could not have known of the wrong. If the claim is brought on behalf of a minor, the repose period lasts until the child’s eighth birthday. An example of this repose concept is an adult patient who receives AIDS from a negligently screened blood transfusion. If the patient has a transfusion and then develops AIDS five years later, the patient has no claim, even if the patient were to initiate legal action on the very day she discovered the negligence. This is because the statute of repose says that, after four years for adults, there is no claim cognizable at law unless there is fraudulent concealment. Mere failure to diagnose is not the same as fraudulent concealment.
www.fmaonline.org
Fraudulent concealment contemplates a physician who learns of a mistake, but then delays in telling the patient. Say a chest x-ray shows a lung lesion. The lesion is missed, and three years later the physician recognizes the original error, but still does not tell the patient. In this circumstance, the patient has seven years from the date of the encounter to bring a claim. In other words, the statute of repose is four years from the date of the incident, regardless of whether the patient knew or should have known of the possibility of malpractice, unless there is concealment, in which case the statute of repose is extended to seven years.
Thus, there are two concepts in play. The statute of limitations runs from the time a patient knew or should have known of the possibility of malpractice. The statute of repose extinguishes a claim, regardless of when or even if the patient knew of the possibility of malpractice, as a matter of public policy. Although the statute of repose may seem harsh, it is the law. Like the statute of limitations, the statute of repose provides a way for physicians to order their affairs, and it provides a point of time in which a physician can be assured that no claim will be brought. Although its application occasionally seems unfair, there is sound public policy embodied in some finality. Physicians also need to understand that there are ways to toll, or freeze in time, the running of the statutes of limitations and repose. Even before a notice of
Florida Medical Magazine winter 2009
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intent (the letter potentially initiating a lawsuit) is sent to a physician, the plaintiff can obtain an automatic 90-day extension of the statute of limitations. This is done by filing a pleading in the courthouse in which the action may be brought, indicating that the extension is sought. No notice need be given to the potential defendants. This act of filing alone will extend the statute of limitations for 90 days. The purpose of this 90-day extension is to address a claim that comes to a plaintiff’s lawyer late in the game, near the two year timeframe, and with insufficient time on the statute of limitations to accomplish the “reasonable investigation” necessary before a notice of intent can be served. Again, the 90-day extension is “free.” It cannot be denied, does not require a hearing and does not require notice. The goal of the tolling is to allow for a reasonable investigation before a notice of intent is served, in which a plaintiff’s lawyer must verify that there is valid reason to believe that there is a claim of negligence. Typically an affidavit accompanies a notice of intent, and the automatic extension is a method to assure a reasonable period of time for a potential plaintiff’s lawyer to obtain an affidavit demonstrating that the potential action is not frivolous on its face.
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Finally, once presuit screening ends, there is at least 60 days from that time, or the time remaining on the statute of limitations, whichever is longer, within which a plaintiff may file suit. Once a suit is filed, the law allows 120 days to serve the defendant. Even that time can be extended when good cause can be shown to the court. That extension also may be obtained without giving notice to the defendant. The great Yogi Berra once said, “It ain’t over until it’s over” and in the complex world of litigation, it may seem that the time for bringing a claim is just that – never over. While I doubt Yogi knew much about the intricacies of Florida law and the statutes of limitations and repose, his words cannot help but to come to mind when one is in the thick of a lawsuit.
For this reason, I often advise clients to not try to figure out a date beyond which no litigation may be brought or to worry about a lawsuit until one comes. Only once the claim comes, will we look backwards and try to figure out if there is a statute of limitations or repose defense. While we’re talking about sayings, it could be said that a statute of limitations defense is “as rare as a hen’s tooth.” I think it is reasonable to assume that four years after an incident, the statute of repose likely would bar the action. However, in the complex world of medical malpractice litigation, Yogi’s words ring true time and again. Tom Dukes is a Board Certified Civil Trial Lawyer. He practices in Orlando in the field of medical malpractice defense with McEwan, Martinez & Dukes, P.A. Tom is a former President of the Florida Defense Lawyers Association. You can contact Tom at tdukes@ mmdorl.com.
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at What Cost?
by John Tyler
The ongoing economic slide
continues to hinder the efforts of working professionals, including those in so-called “recession proof” industries. For physicians, it appears that no specialty is immune and the consequences reach further than simple dollars and cents. Those who primarily offer elective procedures, such as plastic surgeons, are seeing a decline in demand as Americans continue to tighten their belts. Unfortunately, a growing number of patients are beginning to forego necessary treatments and medications, putting their health at risk even in the face of grave consequences. As more and more patients neglect health care to preserve their finances, physicians are left facing a troubling new reality.
Pay i n g t h e P r i c e
Research has shown that the number of patients avoiding or misusing prescription medications is reaching alarming new heights. According to the Center for Studying Health System Change, a nonprofit research group in Washington, D.C., one in seven people under the age of 65 goes without necessary medication because they cannot afford it.1 This figure spans a wide range of demographics, reaching from the uninsured and chronically ill to those who are relatively healthy with employer-sponsored coverage. 1
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As the economy continues to decline, the numbers likely will increase. Physicians understand that, for patients with serious health concerns such as heart disease or diabetes, failure to medicate properly can be life-threatening. However, statistics reveal that patients are becoming more concerned with short-term financial losses rather than their long-term health. “Patients are taking medications differently, or not taking them at all,” says Kathy Hebert, MD, a cardiologist and associate professor at the Miller
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Florida Medical Magazine winter 2009
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“Physicians who aren’t willing to negotiate business will likely lose out.” School of Medicine at the University of Miami. “If they’re supposed to take a medication three times a day, they’ll take it once; if it’s supposed to be once a day, they’ll take it every other.” For these patients, the consequences are threefold — they are bearing the cost of medication, as well as the side effects, without receiving any therapeutic benefit. To make matters worse, many patients also are forgoing essential preventive care. According to Hebert, if the deductible does not cover the cost, patients are not willing to pay. “These patients seem to take colonoscopies or mammograms as if they are electives, or even luxuries.” This neglect can allow potential lifethreatening illnesses to go unnoticed, costing patients far more in the long run. Meeting the Demand
According to Florida Medical Association (FMA) Speaker, Alan B. Pillersdorf, MD, a plastic surgeon in Palm Springs,
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the demand for elective cosmetic procedures has shown a decline, but not as much as one might think. In fact, among certain demographics, the demand actually has increased. “Older patients, those living off of their dwindling retirements, are still coming in for tummy tucks, eye lifts, and such,” says Pillersdorf. “They seem to think that, since they are losing money, they might as well spend what they have on something they can enjoy.” The greatest drop has occurred among younger cosmetic patients — those who cannot afford a procedure or qualify for the necessary credit. “It’s to the point where these patients are determining whether or not they have the money to put gas in their cars. They may want a breast enhancement, but they simply cannot afford it.” As the economy forces individuals to make tougher financial decisions, the business of medicine becomes more apparent. Currently, many cosmetic patients have begun a practice Pillersdorf has seen for years in South
Florida Medical Magazine winter 2009
These patients seem to take colonoscopies or mammograms as if they are electives, or even luxuries. Florida — bargaining. Patients are now comparisonshopping medical practices, asking for price-matching and even negotiating multiple procedures for a discount. “You have to ask yourself, what makes sense: making something or making nothing?” says Pillersdorf. He believes that physicians who primarily perform elective procedures to survive ultimately must accept and abide by market forces. “Physicians who aren’t willing to negotiate business will likely lose out.”
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Tak i n g Co ntro l
Although there is no way for physicians to manage or monitor patient behavior, they can offer careful advising and low-cost opportunities to encourage patients to stick with their treatments. Dr. Hebert’s practice has explored numerous successful avenues to cut costs and ensure that patients are not afraid to pursue the care they need. “Generic drugs make a huge difference,” she says. She attributes her practice’s success in treating congestive heart failure to programs at Wal-Mart and Target, which provide certain essential prescriptions at a major discount. “We hand out lists of the medications available from these programs,” says Hebert. “We make sure the patients are able to receive the care they need at a price they can handle.” Dr. Hebert’s practice also received a grant that allows them to provide IV Lasix to patients without an appointment for no cost. This procedure performed in an emergency room would cost upwards of $5,600. She believes these and other opportunities are out there for physicians who are willing to search proactively and with an open mind. None of these opportunities or advantages will have their intended effect, however, unless patients are well-informed. “We spend an hour with patients covering disease management,” says Hebert. “We teach them to weigh themselves every day, to know when they should adjust their medications and the appropriate way to do so.” Focused one-on-one interaction with patients may curb preventable emergency room visits or unnecessarily extended or boosted treatments. Patients who fully understand how to take care of themselves, and the consequences of failing to do so, are less likely to put their health at risk. In the current economic climate, finding ways to minimize risk will likely prove rewarding now and long into the future for physicians and patients alike.
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Florida Medical Magazine winter 2009
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Finding New Value in Your Medical Practice by John Tyler
Without exception
the new American economy is forcing industries to reevaluate how they do business. The fact is that many physicians no longer can afford to continue business as usual. In many practices, everything from office hours to staffing to equipment is being analyzed closely for efficiency and profitability, with inevitable cuts on the horizon. For physicians who are proactive and willing to think beyond the norm, there are a number of ways to acclimate a practice to weather the economic downturn. In most cases, resources that may seem unnecessary or ineffective simply need to be re-tooled to find new value.
Right on Schedule
Patients are at the heart of any medical practice – as the patients go, so goes the practice. Many patients are tightening their belts and often working longer, irregular hours, both of which put the time and expense of doctor visits into a new light. “For years and years, doctors have been rigid,” says Josh Plummer, a practice management consultant and President of PracticeWorx in Orlando. “They work Monday through Friday, 9am to 4pm, with appointments scheduled well in advance. Today, flexibility is at a premium,” he says.
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The most obvious solution to increase flexibility is to see an increased number of walk-in patients or same-day appointments. Some practices have reorganized their scheduling to accommodate walk-in patients first, leaving only a small number of long-term appointments available. However, this radical transition is not the only option for physicians looking to shake things up. “One or two days a week is enough,” says Plummer. “Practices might stay open an extra hour or two to accommodate walk-ins, or one or two weekends a month.” An added benefit is that the more time that a practice stays open and busy, the greater the cost-effectiveness of staff and equipment.
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Get Connected
According to Plummer, another transition many physicians are slow to make is the transition to the digital age – and he does not mean EMR. “The internet has revolutionized business across the board,” he says. “There are so many inexpensive ways medical practices effectively can tap into the internet, and yet few have taken full advantage.” Many of the daily headaches and hassles experienced by a practice’s administrative staff can easily be handled online. The thirty minutes of paperwork that new patients need to fill out can be integrated into a website, allowing patients to complete them before they ever walk through the door.
A more progressive practice might use the internet for patient accounting. HIPPA-compliant software is available to securely accept and update a patient’s data right from the patient’s home computer. This renders the complicated human billing process practically obsolete. “The amount of money this kind of software can save a practice on paper alone, and the satisfaction it provides patients, are off the charts,” says Plummer. This is in addition to other benefits, such as e-prescribing and even increased direct communication between physicians and patients. For example, medical practices often are bombarded with calls for prescription refills. The subsequent chain of events is typically a model of inefficiency. “The receptionist takes these calls and makes notes,” says Plummer. “Then these notes are passed on to the nurse, who then passes them on to the doctor.” Using the internet, practices can offer patients online refill requests submitted directly to the physician by email. “This alone can free up a considerable amount of staff time and resources,” Plummer says.
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Florida Medical Magazine winter 2009
The question remains: why don’t more practices take advantage of the internet? Patient satisfaction is crucial to the profitability of any transition a practice makes. An easy way to ensure that these priorities line up is to use patient satisfaction surveys. “No one can tell you whether or not a change is working better than your patients,” says Plummer. Simple questionnaires can be handed out after visits or integrated online, further decreasing expenses. By including patients in the process, physicians can find successful, innovative ways to change their practices to the benefit of everyone. The question remains: why don’t more practices take advantage of the internet? The answer isn’t money. The cost of designing a website is reasonable and the long-term expense of housing and monitoring is negligible. “For whatever reason, the internet has been slow to build steam among physicians,” says Plummer, “but for those who take advantage, the sky is truly the limit.” P a r a d i g m S h i ft
Most successful transitions stem from a willingness to try new things – to create and execute an unconventional plan. For physicians looking to improve the effectiveness of their practices, this could mean taking a top-to-bottom inventory, assessing the value of every aspect. “It really is a matter of scrutiny,” says Plummer. “You must ask: what does my practice need?” The litmus test is simple. If a staff member, piece of equipment, or procedure creates a viable profit margin, keep it. If not, it may be time to reconsider. Of course, there are no universal answers, only what is right for each individual practice. The traditional medical practice, with its well-furnished waiting room and stateof-the-art equipment no longer can be taken for granted. Entrepreneurial curiosity can go a long way to helping physicians, even without substantive business knowledge. A number of factors ultimately determine what a physician needs to practice medicine at the level he or she desires. For example, how many patients are seen every day? What kind of care is most commonly necessary? Does the physician tend to stay in the office or spend a majority of time in hospitals? Answering these questions with an open mind can help physicians discover innovative solutions to problems, shaping their practices for the future.
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by John Tyler
Tourist Season
Are Patients Traveling Abroad for Discounted Care?
For centuries
patients have traveled great distances in pursuit of quality medical care. Over the last five years, however,
there has been a shift in the nature of these excursions. In the past, patients from less-developed countries predominantly came to the United States or other developed countries for care; a recent phenomenon has shifted the international balance. Like never before, American patients are beginning to go abroad for medical care as the market for health care becomes more global. In response, many American physicians and health leaders have begun efforts to maintain and improve the way the United States attracts patients in an increasingly global economy. T o u r i s t Att r a c t i o n
The most obvious catalyst for outbound American medical tourism is the mounting cost of health care. The quality of care abroad has improved and remains at a significant discount from prices stateside. Many lessdeveloped nations that previously suffered from a substandard quality of transportation, communication, or environmental health conditions have begun to raise the bar. In fact, places like Thailand and Argentina have seen
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an influx of consumer-orientated, high-quality medical facilities that actively promote their discounted services in the United States and Western Europe. Many are even offering packaged deals, including airfare and accommodations at resort hotels. What is the impact to American physicians? According to Renee Marie Stefano, Esq., co-founder of the Medical Tourism Association in West Palm Beach, believes the
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Goldschmidt’s vision is to turn the city of Miami, and ultimately the state of Florida, into a “Medical Destination.” effects are positive. “In some ways, the advent of medical tourism takes some of the financial burden off domestic physicians,” says Stefano. “Some patients who travel to pursue less-expensive care are doing so because they cannot afford to pay the cost at home. This certainly is preferable to leaving American physicians with unpaid bills.” Nonetheless, with a looming national shortage of physicians amid an ongoing debate on health care reform, any trend that draws patients away from the United States for health care is a cause for concern. Risk and Reward
For all the potential savings, patients who seek care abroad do face risks. Not all developed nations regulate health care or license their physicians as strictly as the United States. In the case of malpractice, patients could find themselves with little or no legal recourse. Even after a successful procedures, patients are unlikely to remain in a foreign destination long enough to see the same physician for follow-up visits. This can leave the subsequent stateside physicians at a significant disadvantage, as international physicians are not bound by FDA regulations in terms of procedures or prescriptions. The highly-variable nature of outbound medical tourism has caught the attention of the American Medical Association. Most recently, the AMA has focused on the advent of unproven foreign stem-cell treatments. Facilities that offer these treatments take full advantage of operating beyond the confines of American regulation; however, according to Stefano, this is not always a bad thing. Some procedures have been approved overseas for years, giving some physicians years of experience. For example, hip resurfacing, which has been available abroad for years, was only approved in the United States in 2006. “Often the FDA is late to approve procedures that have been available elsewhere for quite awhile,” says Stefano. “Patients who wish to see the physician with the most training and experience in these procedures would need to look internationally.” A Global Market
As the market for health care becomes more global, American physicians and health care organizations have begun efforts to stay ahead of the international curve. Stefano attributes part of the decision to establish the
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Medical Tourism Association in West Palm Beach was its proximity to medical destinations in Latin America. At the University of Miami Miller School of Medicine, Dean Pascal J. Goldschmidt, MD, is taking similar advantage of his location. Goldschmidt’s vision is to turn the city of Miami, and ultimately the state of Florida, into a “Medical Destination.” He believes that, as the world grows smaller, its population grows smarter. “The number one ingredient of attractive medicine is quality,” he says. “The creation of a medical destination relies entirely on the ability to collect the best physicians and nurses in the world. In the United States, we have many of the best.” Goldschmidt also acknowledges that Miami offers many other advantages that might attract medical tourists. “Miami has always been welcoming of international travelers. We have great weather, great culture, some of the best retail, and great entertainment. The city is already committed to tourism.” Goldschmidt acknowledges that, although the United States is leading the world in medical quality, but when it comes to providing access to care, there certainly is room to improve. He also acknowledges the unique place academia holds in solving this problem. “In America, 70 percent of indigent patients are seen by university physicians,” says Goldschmidt, who is current working with Deans John A. Rock, MD, of Florida International University and Anthony J. Silvagni, DO, of Nova Southeastern University, to find new ways to increase access to care in South Florida. Improving access to care locally is an important first step in succeeding globally and fulfilling Goldschmidt’s vision. Many private medical practices in South Florida already see a significant number of international patients. In March of 1999, a group of the region’s major hospitals came together to form the Miami Medical Alliance, also known as “Salud Miami” in Spanish, or “Saude Miami” in Portugeuse. Now known as Salud International, this organization markets health care opportunities to patients all over the world, partnering with travel agents, hotels, and airlines, and taking full advantage of the internet. Since 2000, Salud International successfully has brought thousands of international patients to South Florida for medical treatment.
Florida Medical Magazine winter 2009
25
Coming Soon
According to a study from the Deloitte Center for Health Solutions, an estimated 750,000 Americans went abroad for medical care in 2007.1 The Center predicts a 100% increase in the next two years, based on a survey taken last year showing booming consumer interest. Still, the market for inbound medical tourism remains considerable. Last year, roughly 400,000 individuals traveled from around the world to the United States for care, generating upwards of $5 billion in revenue. These patients came primarily from South America, Canada, and the nations in the Middle-East region. The most important factors that will determine the future of medical tourism in America, and the balance between inbound and outbound patients, include cost, quality, and availability of care. As the health care reform debate continues in Washington, much remains in question. However, many can agree that the quality 1
and availability of American medicine remain second to none and will continue to draw international patients seeking the best available care. To most effectively market the quality of American medicine abroad, new waves of cultural sensitivity and adaptation are becoming a necessity. Physicians and hospitals looking to attract international patients must consider language, diet, and customs or beliefs like never before. Ultimately, the world continues to grow smaller and virtually every industry is forced to adapt. The competition inspired by medical tourism has given way to increased cultural sensitivity and global communication in American health care, motivating many physicians and hospitals to find innovative ways to attract and care for patients. As this trend continues, Florida will remain at the epicenter as both a budding “Medical Destination� and a focal point of international medical tourism.
http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalTourismStudy(1).pdf
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Florida Medical Magazine winter 2009
27
The Road Less Traveled: Carl L. Brumback, MD
When Carl L. Brumback, MD,
graduated from medical school, he could not
have known where his life would lead. He quickly became accustomed to taking the road less traveled, forging new paths that today remain vital to public health in Florida. From the halls of Alcatraz to the rubble of post-war Germany, Dr. Brumback’s life ultimately led him to Palm Beach County. There, working to improve the lives of the public including indigent migrant workers, he founded a health department that now stands as a model for the nation. Dr. Brumback’s great passion for health care and can-do spirit continue to positively affect the lives of others, leaving a legacy that only grows stronger with time.
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A Life Less Ordinary
After receiving his medical degree from the University of Kansas School of Medicine, Brumback headed west to pursue a residency in San Francisco, beginning his career in a United States Marine Hospital. During this period, nearby Alcatraz Island still was housing some of America’s most dangerous criminals. Only two physicians worked in the infirmary, and when one of them became ill and had to retire, the marine hospital began rotating residents. “My wife, Lucile, would take me to the pier. She was a real partner to me.” Dr. Brumback remembers. “Prison workers picked me up in a boat and took me to the island. Then two guards escorted me through six gates to the infirmary and physician’s office.” During a shift, Brumback would conduct rounds along “Broadway,” the cell block corridor, examining prisoners under the watchful eye of armed guards. During this time, he examined crime figures such as Robert “Machine Gun” Kelly, a notable prohibition-era gangster, and Robert Franklin Stroud, better known as the “Birdman of Alcatraz.”
After Brumback worked in San Francisco, he served as a physician in the United States Army in Europe where World War II turned in favor of the Allies, leading ultimately to victory. As a result, the United States Army began discharging soldiers. Unfortunately, they discharged far more physicians than necessary and created a shortage in war-torn Germany. “There were ships sunk all over the harbor,” he says. “They loaded us on a train into what they called forty-and-eight cars, because they could hold either forty men or eight horses.” The train stopped in Cassel, Germany, where Brumback would take post as Deputy Commander of a military hospital. “Cassel was pretty well pulverized,”
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“I told him I wanted to tackle every conceivable health problem and develop the resources to do so.”
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he says. “There were only a few buildings intact along the outskirts.” One of these buildings had served as headquarters to Hitler’s Western Commander, who had vacated his office so hastily that he left his epaulets and Nazi insignia behind in their display case. “The hospital commander chose to leave them where they were,” says Brumback. “They ended up being quite the conversation piece.”
professor was on his way there to aid in reorganizing the health system and Brumback was invited to join him. After a few months in Tennessee, the two men achieved great results and Brumback became director of the project. Yet, he felt compelled to move on. “I wanted to get out of federal service,” says Brumback. “I wanted to get into communities to address health problems affecting people in genuine need.”
After 16 months in Europe, Brumback returned to the United States and decided to pursue additional postgraduate work at the University of Michigan. There, he received a Master of Public Health degree and developed a passionate interest in providing care to underserved communities. His desire was simple – he wanted to combine the efforts of the public and private sectors, increasing the level of cooperation between physicians and public health workers to create a better system of care. Members of the Michigan faculty alerted Brumback to an opportunity in Oak Ridge, Tennessee, at the Atomic Energy Commission. A Michigan
Aware of Dr. Brumback’s work at the Atomic Energy Commission, Florida State Health Officer, Wilson T. Sowder, M.D. recommended him to create a county health department in Palm Beach. “I told him I wanted to tackle every conceivable health problem and develop the resources to do so. He told me this was just the place I was looking for.”
Florida Medical Magazine winter 2009
From the Ground Up
Soon after arriving, Brumback became involved in organized medicine. He joined the Florida Medical Association (FMA) and also the Palm Beach County
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Medical Society (PBCMS). Before taking his post at the health department, the PBCMS assembled a committee of physician leadership to interview him. “They wanted to know what my plan was,” says Brumback. “I told them that I didn’t have one, but I committed to them that we would work together to identify the county’s health problems and to identify solutions.” Dr. Brumback and the physicians of Palm Beach County were quickly on the same page. He soon became a member of the Palm Beach County Medical Society’s Executive Committee and thus began a journey toward building one of the finest public health systems in the country, which has as its foundation a strong partnership between public health and the private practice of medicine. The immediate challenges were overwhelming. “When I took over as director of the health department in 1950, there were 114,000 residents in the county, and I had a budget of $92,000,” Brumback says. To make matters worse, Palm Beach County had one of the largest populations of migrant farm workers in the nation — roughly 55,000. “There were very few physicians in the area at the time and even fewer specialists. By the time many of the migrant workers received medical attention, their cases were terminal.” Their living conditions were abysmal, making homes out of packing crates in sparse labor camps. Dr. Brumback began taking photographs, documenting the misfortune of the migrant workers. He contacted groups like the Florida Christian Migrant Ministry and organized efforts to raise awareness, funding, and cooperative action. This led him as far as Washington, D.C., where he gave a presentation to a national council of churches and ministries, sharing his photographs and eyewitness accounts of the problem. Although he had no trouble stirring interest in solving the problem, funding was another story. Then, in 1954, Brumback received a federal grant to study the health of migrant workers that resulted in a book by the study’s principal investigator, Earl L. Koos, PhD, head of the Department of Social Anthropology at Florida State University. The book, titled, They Follow the Sun, further documented Florida’s struggling population of migrant workers. The two men began communicating and sharing ideas.
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“I can still see him,” says Brumback. “I can still hear his voice. He listened to us, then he looked at me and said, ‘What you’re proposing is the wave of the future.’” “Dr. Koos understood that addressing the problem would require more than medical care,” says Brumback. “These people needed aid in every conceivable way, and providing it would require a team effort among physicians, educators, and public health workers.” Dr. Brumback and Dr. Koos approached Elizabeth Peabody, MD, a pediatrician with the United States Children’s Bureau, about funding a project. “The woman was a magician,” says Brumback, laughing. “She came up with $250,000 to see what our proposed team could do in Palm Beach County.” The team would use two new health centers in Belle Glade to treat migrant workers and their families and ultimately attract attention from Washington. Dr. Brumback’s program became a national model, the inspiration for a multi-million dollar federal program to build similar migrant health programs throughout the United States. In 1962, Brumback was appointed as a member of a national committee responsible for supervising these programs to ensure their success.
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As Brumback fought to improve the lives of migrant workers, he still had a county health department to run. Unfortunately, with limited funding, he had very few obvious resources. “I knew I needed an assistant,” he says, “but I did not have the money to afford the quality of physician I needed.” This gave Brumback an idea. Rather than looking for experienced physicians at a discount, he developed a residency program, looking to attract talented young graduates from the nation’s top medical schools. “It was a strange idea,” says Brumback. “Health departments did not house residencies.” Nonetheless, he wrote to the national accrediting board and was approved. One of his first residents, James T. Howell, MD, would go on to become the first Secretary of the Florida Department of Health. Another, Jean M. Malecki, MD, now serves as Director of the Palm Beach County Health Department. Under her guidance, the department has grown rapidly, employing hundreds, with a budget of nearly $70 million. The residency program continues to attract top young physicians from all over the world.
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Many of the groundbreaking programs Dr. Brumback developed over the years in Palm Beach County remain active and have been duplicated by other county departments across Florida. He developed an Environmental Health and Engineering Department to monitor all aspects of air, water, and land pollution. “When I came back in 1950, Palm Beach County had a considerable pollution problem. They didn’t have sewage processing, so we organized a system to deliver it and the standards to enforce it.” Every step of the way, Brumback worked to involve private physicians in public matters. Unfortunately, state laws at the time did not permit general medical care in county health departments. Impressed by his success in aiding the migrant population in Palm Beach, a West Palm City Commissioner approached Brumback about developing similar support systems in the county. “I explained to him that we were limited according to the statutes in terms of providing direct medical care,” says Brumback. “That kind of program simply did not exist.” The two men traveled to Jacksonville and met with State Health Officer Sowder, explaining their desires. “I can still see him,” says Brumback. “I can still hear his voice. He listened to us, then he looked at me and said, ‘What you’re proposing is the wave of the future.’” Dr. Sowder recommended a waiver from state law, allowing Brumback’s efforts to proceed toward revolutionary change for a closer partnership between the public and private sector of health care in Florida. Wave o f the Futu r e
Throughout his career, Dr. Brumback brought “wave of the future” health care to Florida. Serving as Chair of the FMA Public Health Committee, his wisdom, insight, and vision ensured that Florida’s physicians were active in public health decisions throughout the state. He also received innumerable awards and accolades, including the American Medical Association’s highest honor: the Dr. Nathan Davis Award. Yet, perhaps the most impressive characteristics of Dr. Brumback’s career remain his
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day-to-day persistence and clear-eyed vision and resilience in navigating uncharted territory and forging new paths. Even after retiring, Dr. Brumback continued working with the Palm Beach County Health Department Residency Program for fourteen years. Now 95 years of age, Dr. Brumback still lives in Palm Beach Gardens and continues to give lectures promoting the residency program. His goal is to continue the program’s tradition of attracting talented young physicians from all over the world. “I only wish more physicians could take advantage of it,” says Brumback. Generations of physicians and patients alike have benefited from his contributions to medicine and public health in Florida. It stems from a career devoted to creating better opportunities for others and a lifelong commitment to excellence. Today, the influence of Carl L. Brumback, MD, is undeniable and his extraordinary legacy continues to grow.
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Physician to Physician “What impact has the recent economic decline had on your medical practice?”
“Our focus has shifted primarily to cutting costs. I have always believed that a dollar saved is better than a dollar earned, since earned dollars go toward overhead and taxes. We are all partners in my practice with personal accounts and every single one of us is pinching pennies. Naturally, we cannot do much on the revenue side because our reimbursements are so regulated.”
J o s e F. A r r a s c u e , M D , N e p h r o l o g i s t , L a n t a n a
“All practices are seeing increasing numbers of uninsured patients – if they will accept them. As a radiologist in a hospital-based practice, I had to accept them. In the event of catastrophic illness, those who are not insured must choose either bankruptcy or suboptimal care. Efforts to contain costs on a national scale seem to keep trimming away from physicians. The traditional practice of medicine cannot continue on the current course.”
James A. Clemmons, MD, Primary Care Physician, Chipley
“My referrals have been slow for quite some time because primary care physicians are not seeing as many new patients as before. Our office has been forced to downsize. The current staff is handling twice as much work as before. While our total number of patients may not have decreased, for reasons such as loss of insurance coverage or economic hardship, their demands have increased. We are struggling to provide exactly the same service as before for them.”
Anil K. Mandal, MD, Nephrologist, St. Augustine
“We are seeing a booming number of uninsured. The risk for catastrophic medical events all but guarantees that some will have to choose either bankruptcy or simply going without care. It seems like many efforts to contain costs on a national scale keep trimming away from physicians, and for any medical practice to survive, this simply cannot continue.”
James M. Zaenglein, MD, Radiologist, Jacksonville
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Florida Medical Magazine winter 2009
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S U P P L E M E N T The Economic Impact of Private Practice Physicians’ Offices
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Florida State University Center for Economic Forecasting & Analysis
contents Executive Summary: Overview & Goals K e y F i n d i n gs I n t r o d u c t i o n : W h y st u d y e c o n o m i c i m p a c t ? B a c kg r o u n d o n F l o r i d a ’ s P h y s i c i a n W o r kf o r c e Data a n d Meth o d o lo gy G l o ss a r y o f T e r m s F i n d i n gs : E c o n o m i c C o n t r i b u t i o n s o f P r i v a t e P r a c t i c e Ph ys i c i a n s to Flo r i da’ s Eco n o m y
A. Overall Impact on Employment B. Overall Impact on Total Economic Activity C. Overall Impact on Real Disposable Personal Income D. Overall Impact on State and Local Government Revenues E. Individual Impact of Physicians by Specialty F. Overall Impact of Physicians by Specialty: Employment G. Overall Impact of Physicians by Specialty: Total Economic Activity & Income H. County-Level Impacts of Physicians: Employment & Total Economic Activity I. Comparing the Impact of Physicians’ Offices to Other Key Industries in Florida F i n d i n gs : T h e E c o n o m i c I m p a c t o f F l o r i d a ’ s P h y s i c i a n S h o r t a g e
A. Impact of Increasing Florida’s Physician-to-Population Ratio to the National Average B. Impact of Expanding Florida’s Physician Residency Program to the National Average D i s c u ss i o n : T r e n d s i n F l o r i d a ’ s P h y s i c i a n P r a c t i c e s a n d Ph ysi ci a n Sh o r tage D i s c u ss i o n : F a c t o r s t h a t C o n t r i b u t e t o Flo r i da’ s Ph ys i c i a n S h o r tag e
A. Structural Factors B. Regulatory and Policy Factors Liter ature Revie w : Previous Rese a rch o n the Eco n o m ic Im pac t of H e a l t h c a r e P r o f e ss i o n a l s
Nationwide Studies Regional Studies Florida-Specific Studies Hospital and Rural Setting Studies Research Team Appendixes References & End Notes
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Executive Summary: Overview & Goals This study estimates the economic impact of private practice physicians’ offices in Florida. It does not include physicians that are based in hospitals or other health care venues such as nursing homes or correctional facilities. The study utilizes the Regional Economic Models, Inc. (REMI) input-output model, which captures interrelationships among industry sectors and measures the impact of changes in economic variables on overall economic activity. The study: 1. Estimates the economic impact of private practice physicians on Florida’s economy, in terms of employment, real disposable personal income (wage and salary income after taxes), Total Economic Activity (“output”), and government revenues generated by those physicians’ offices; 2. Estimates the relative economic impact of physicians in key specialties within the practice of medicine, and offers county-level breakdowns of all impact data; 3. Estimates the economic impact of a physician shortage in Florida and discusses the factors influencing the practice of medicine in Florida; 4. Provides background on characteristics of Florida’s current physician workforce and a literature review of previous economic impact studies; and 5. Illustrates the importance of considering “economic impact” in healthcare policymaking, and highlights key areas of concern for Florida’s private practice physicians.
Key Findings Eco n o m i c I m pac t o f Flo r i da’ s Pr i vat e Pr ac t i ce Ph ys i c i a n s i n 2 0 0 9
In 2009, private practice physicians’ offices in Florida create or support approximately: • 451,500 jobs – which represents five percent of total employment in the state; • $22 billion in real disposable personal income (“Income”); • $56 billion in Total Economic Activity; and • $3 billion in government revenues. Each individual private practice physician in Florida today supports, on average: • 19 additional jobs; • $913,000 in Income for those jobs; and • $2.3 million in Total Economic Activity. Economic Impac t Projec tions for 2020
By 2020, the annual impact of private practice physicians’ offices will include: almost 650,000 jobs; • over $41 billion in Income for those jobs; • $93 billion in Total Economic Activity; and • around $6 billion in government revenues.
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T h e Eco n o m i c I m pac t o f Flo r i da’ s Ph ys i ci a n S h o r tag e
Creating an additional 2,700 Graduate Medical Education (GME) residency positions, to meet the average national ratio of GME residents per state population, will create or maintain an additional: • 34,000 jobs in 2012 to 44,000 jobs in 2020; • $2.4 billion in Income for those jobs in 2012 to $4.1 billion in 2020; and • $4.3 billion in Total Economic Activity in 2012 to $6.3 billion in 2020. Expanding Florida’s ratio of physicians per 100,000 population by 10 percent, to meet the national average of physicians per state population, will create an additional: • 50,000 jobs in 2012 to 65,000 jobs in 2020; • $3.6 billion in Income for those jobs in 2012 to $6.1 billion in 2020; and • $6.5 billion in Total Economic Activity in 2012 to $9.3 billion in 2020.
Introduction: Why Study Economic Impact? Much is known about how the economy impacts the healthcare industry and how access to healthcare improves the quality of life of residents in a community. Less attention has been directed to how the healthcare industry and physicians specifically impact local and state economies. These are important dynamics to measure and understand. Private practice physicians are at the very foundation of the healthcare system and they directly impact the lives of those under their care. Private practice physicians contribute to economic viability at the national, state and local levels, and impact Florida’s economy in many ways: they create jobs and income by employing people, they create demand in the economy by purchasing goods and services from local businesses, and they generate revenue to local governments and the state through taxes and fees. These factors, in turn, lead to increased household spending and greater economic activity within communities. Further, access to care improves the overall health of Florida’s residents, which boosts productivity among employees and leads to greater economic stability for families. Yet these benefits to Florida’s economy by private practice physicians cannot be taken for granted. Florida, like the nation, faces a growing shortage of physicians. The repercussions of this are apparent in terms of access to care, as residents in Florida will have fewer physicians to choose from, will experience longer wait times to receive diagnoses and treatment, and in times of medical crisis, will have a dramatically reduced access to immediate care in hospital emergency departments. A shortage of private practice physicians also has significant economic consequences: when physicians leave the state or leave private practice, Florida loses out on widespread economic benefits. There are several factors that contribute to Florida’s physician shortage, many of which relate to the policy and regulatory environments in which physicians practice medicine. These issues, as well as a description of the demographics and practice trends among Florida’s physicians, will be addressed in this study. With all eyes focused on state and national budgets, lawmakers are faced with a number of important policy decisions that will impact the practice of medicine in Florida. In this context, it is even more important to understand the impact that Florida’s physicians have on the economic vitality of communities. In short, private practice physicians are a key element to the physical and economic prosperity of Florida. The entire state benefits when physicians have a positive work environment in which to practice medicine.
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Background on Florida’s Physician Workforce Florida’s Department of Health (DOH) 2008 Physician Workforce Annual Report1 describes the demographic and professional practice characteristics of the active, licensed physician workforce in Florida. Data were collected via a survey through the physician license renewal process. The response rate was 99 percent, with a total of 30,492 respondents. This represents the 25,850 allopathic physicians that renewed their license in 2008 (50 percent of the state’s allopathic workforce), and 4,839 osteopathic physicians (100 percent of the state’s osteopathic workforce). However, of these respondents, only 71 percent, or 21,610 physicians, indicated that they have an active practice in Florida. The following data describe these 21,610 “active” physician respondents, which is a representative sample of the total number of active Florida physicians.
Basic demographics:
Age 25-45: 36% Over the age of 55: more than 30% Male: 76.9% White/Non-Hispanic: 78% M a i n p r a c t i c e s e tt i n g :
Private office: 60% Hospital inpatient or outpatient: 19.7% Hospital emergency department: 4.9% Nursing home/extended care: 0.53% Ambulatory surgery/free standing diagnostic center: 1.14% Federally Qualified Health Center: 1.52% Governmental clinic setting: 1.8% Other setting: 7.2% D i st r i b u t i o n o f m e d i c a l s p e c i a l t i e s ( i n d e s c e n d i n g o r d e r ) :
Family Medicine: 15% Internal Medicine: 13% Medical Specialties: 13% Surgical Specialties: 12.3 % Anesthesiology: 5.7% Pediatrics: 5.5% Emergency Medicine: 5.1% OB/GYN: 4.6% Psychiatry: 4.4% Radiology: 4.1% Dermatology: 2.3 % Pediatric Subspecialties: 2.1% General Surgery: 2.1% Neurology: 2% Pathology: 1.8% “Other”: 6.8%
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Data and Methodology REMI M o d e l
The REMI Model is a highly regarded input-output tool that is widely implemented to measure the economic impact of proposed legislation, programs or policies. REMI’s advantage is that it is a dynamic econometric model, and can be used to forecast both direct and indirect economic effects over multiple-year time frames. REMI captures interrelationships among industry sectors and measures the impact of changes in economic variables on overall economic activity. The REMI model used for this analysis was specifically developed for the state of Florida and includes 169 industry sectors. REMI is used by the Florida Legislature’s Division of Economic & Demographic Research, the Florida Agency for Workforce Innovation, other government agencies, universities, and private research groups that evaluate economic impacts across the state and nation. Additional information about REMI is provided in Appendix A. Methodology
Many methods can be used to estimate the impact of a particular sector on the economy. Historically, most impact studies have taken into account only the direct, short-term impacts of an industry sector or an investment. However, the economic impact of physicians’ offices is not limited to its direct impact. The economic activity generated by physicians’ offices also creates jobs and productive output in other business sectors throughout the state. There are three different levels of impact: direct, indirect, and induced. See the Glossary of Terms for an explanation of each impact. REMI analysis includes all three levels of impact. The REMI variable for the offices of health practitioners includes offices of private practice physicians, offices of dentists, and offices of other health practitioners. Using Census Bureau data, it was determined that private practice physician offices account for 66 percent of offices of health practitioners in Florida. Therefore, in this economic impact estimate, the employment for offices of health practitioners was reduced to 66 percent in order to capture the full contributions of only private practice physicians. The model then estimates the economic impact of private practice physicians’ offices on key variables by comparing results that are derived with and without the economic activity of physicians’ offices included in the model.
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The Economic Impact of Private Practice Physicians’ Offices in Florida
Research Data D a t a f o r t h i s st u d y w e r e o bt a i n e d f r o m s e v e r a l s o u r c e s :
Data Sou rce :
North American Industrial Classification System (NAICS), maintained by the US Bureau of the Census2
A ppli c ati o n :
NAICS includes economic output data on more than 700 industry sectors for each of the 3,066 US counties. Physicians’ offices report their economic activity under NAICS code 62111, including the total number of full-time employees (or full-time equivalents), the dollar value of their payroll, and the revenue of the business. The data covers health practitioners with the degree of M.D. (Doctor of Medicine) or D.O. (Doctor of Osteopathy) who are primarily engaged in the independent practice of general or specialized medicine and/or surgery. Hospitals are reported under a separate code. (See notes below.)
State Statistical Abstract published by University of
County-level economic data for private practice
Florida Bureau of Economic and Business Research3
physicians’ offices.
Council for Education Policy, Research and Improvement4
Estimates of physician shortage
US Bureau of the Census 5
Estimates of physician shortage
Florida Occupational Employment and Wages and the DOH Physician Workforce Report, 2008.6
Estimate number of physicians by specialty and their average wages, as well as portions of specialties within counties.
N ote s o n Data
The physician workforce data which were used to estimate the economic impact by specialty, includes all physicians, regardless of practice venue, but NAICS economic data only includes private practice physicians. Hospital-based physicians are not captured. Therefore, specialty-specific impact estimates underestimate the true impact of private practice physicians. In the REMI analysis, NAICS data are used to estimate direct, indirect and induced impacts. The county-level and specialty-specific data were used to assign a proportion of that total to each county and medical specialty. The projections in this study are based on current economic structure and data and do not include any adjustment for future policy programs affecting private practice physicians in the state. The study does not capture the greater health “benefits” of services provided by private practice physicians’ offices, such as the increased productivity of a “healthier” workforce. Finally, all figures in this study are in 2009 real dollars.
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Glossary of Terms D i r e c t I m p a c t refers to economic impacts created directly by the business activity of private physicians, including the purchase of goods and supplies, as well as the support of office employees. I n d i r e c t I m p a c t refers to impacts created by producers of intermediate goods and services that are purchased by the physicians’ office. This includes the suppliers’ hiring of employees to support the physicians’ purchases. I n d u c e d I m p a c t refers to the subsequent impact from wages paid to households by both directly- and indirectly-affected businesses. In other words, induced impact includes purchases made by households which receive wages from employment in physicians’ offices or from companies that provide goods or services to physicians’ offices. T o t a l S t a t e E m p l o y m e n t (“Employment”) includes estimates of the number of full-time plus part-time
jobs, by place of work, and includes employees, sole proprietors and active partners. This estimate includes all persons employed by physicians’ offices as well as persons employed by companies whose business is supported by the economic activity of physicians’ offices. Unpaid family workers and volunteers are not included in the estimate. Employment is affected by output (see below) and changes in labor productivity. In the REMI analysis, employment includes direct, indirect and induced impacts. T o t a l E c o n o m i c A c t i v i t y (“Output”) is the amount of production, including all intermediate goods
purchased, as well as value added through these purchases (compensation and profit). Output can also be thought of as sales or revenues, and includes exports to other parts of the nation or world. An increase in output is caused by an increase in demand, an increase in market share, or an increase in international exports. In the REMI analysis, Total Economic Activity includes direct, indirect and induced impacts. R e a l D i s p o s a b l e P e r s o n a l I n c o m e (“Income”) refers to personal income minus taxes. This
estimate includes all persons employed by physicians’ offices, as well as persons employed by companies whose business is supported by the economic activity of physicians’ offices. In technical terms, real disposable personal income equals disposable personal income deflated by the PCE-Price Index (Personal Consumption Expenditure Price Index). Increases in personal income translate into more economic activities and local and state tax revenues. In the REMI analysis, income includes direct, indirect and induced impacts. G o v e r n m e n t R e v e n u e s includes income available to state and local governments through the payment of taxes and fees. In the REMI analysis, this measure includes direct, indirect and induced impacts.
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Findings: Economic Contributions of Private Practice Physicians to Florida’s Economy A . Over all Impac t on Employ ment ( Char t 1)
Chart 1 represents that, in sum, private practice physicians in Florida support over 450,000 jobs in 2009. This includes direct office employees, as well as jobs created in other sectors of Florida’s economy as a result of economic activities stimulated by physicians’ offices. For example, when physicians purchase supplies, the supply companies must employ people to support the sales, manufacturing, and so on. These jobs represent over five percent of total state employment. The annual number of jobs created or maintained by physicians’ offices is expected to reach 650,000 by 2020. See Appendix C for a county-level breakdown of employment impacts.
Chart 1: The Number of Jobs Created or Maintained Chart 1: The Number of Jobs Created or Maintained by by Private Practice Physicians’ Offices Private Practice Physicians' Offices
700,000 600,000 500,000
451,500
468,600
486,700
504,100
522,400
542,300
560,300
578,800
596,900
614,600
632,400
649,400
400,000 300,000 200,000 100,000 0 2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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B . Over all I m pac t o n Total Eco n o m i c Ac tiv it y ( Ch a r t 2 )
Chart 2 represents the contributions by Florida’s private practice physicians to “Total Economic Activity.” Total economic activity is a measure of both final and intermediate goods and services produced in Florida. The contribution of physicians’ offices to Total Economic Activity is estimated to increase from $55.7 billion in 2009 to $93 billion in 2020. Total Economic Activity is the amount of production, including all intermediate goods purchased, as well as value added through these purchases (compensation and profit). Output can also be thought of as sales or revenues, and includes exports to other parts of the nation or world. An increase in output is caused by an increase in demand, an increase in market share, or an increase in international exports. In the REMI analysis, Total Economic Activity includes direct, indirect and induced impacts. See Appendix E for a county-level breakdown of Total Economic Activity impacts.
Chart EconomicContributions Contributions Physicians’ Offices to Chart 2: 2: Economic of of Physicians' Offices the Total Economic Activity (In Billions, to the Total Economic Activityand in 2009 Dollars) (In Billions and in 2009 Dollars) $100 $90 $80 $70 $60
$55.7
$58.5
$61.5
$64.5
$67.8
$71.4
$74.8
$78.3
$81.9
$85.6
$89.3
$93.0
$50 $40 $30 $20 $10 $0 2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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C . Over all Impac t on Re al Disposab le Per sonal Income ( Char t 3 )
Chart 3 represents the contribution of private practice physicians’ offices to real disposable personal income, which equals personal income (wage and salary), minus taxes. This estimate includes the income earned by all persons employed by physicians’ offices as well as persons employed by companies whose business is supported by the economic activity of physicians’ offices. In technical terms, this measure is calculated as the sum of wage and salary disbursements, supplements to wages and salaries, proprietors’ income with inventory valuation and capital consumption adjustments, rental income of persons with capital consumption adjustment, personal dividend income, personal interest income, and personal current transfer receipts, less contributions for government social insurance. Chart 3 shows that, after adjusting for inflation, physicians’ offices contribute $22.2 billion to Income in 2009. This contribution will reach to $41.3 billion in 2020. See Appendix F for a county-level breakdown of Income impacts.
Chart 3: Economic Contributions of Physicians’ to Chart 3: Economic Contributions of Physicians' Offices Offices to Real Disposable Personal Income and in 2009 Dollars) Real Disposable Personal Income (In Billions, (In Billions and in 2009 Dollars)
$45 $41.3 $39.6
$40 $35 $30.9 $30 $25.6 $25
$22.2
$27.3
$32.6
$34.3
$36.1
$37.8
$29.0
$23.8
$20 $15 $10 $5 $0 2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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D. Ov e r a ll I m pac t o n S tate a n d Lo c a l G ove r n m e n t R e ve n ue s ( Ch a r t 4 )
Chart 4 represents the contributions of private practice physicians’ offices to state and local government revenues by paying taxes and fees. In the REMI analysis, this measure includes direct, indirect and induced impacts. The REMI model estimates that physicians’ offices contribute around $3 billion to government revenues in 2009, and that this contribution will double to almost $6 billion per year by 2020.
4: State andLocal Local Government Revenues ChartChart 4: State and Government Revenues Generated by Physicians' Offices Generated by Physicians’ Offices (In Billions, and in 2009 Dollars) (In Billions and in 2009 Dollars)
$7
$6
$5
$4
$3
$2.9
$3.1
$3.4
$3.7
$3.9
$4.2
$4.5
$4.7
$5.0
$5.3
$5.5
$5.8
$2
$1
$0 2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
E . I n d i v i d u a l I m p a c t o f P h y s i c i a n s b y S p e c i a l t y
Estimating from the DOH Physician Workforce Annual Report, there are approximately 56,539 physicians that hold a Florida medical license (this includes 51,700 allopathic physicians and 4,839 osteopathic physicians.) Of these, 71 percent, or 40,142 physicians, indicate that they are in active practice in Florida. Of these, approximately 60 percent, or 24,085, indicate they are in private practice. According to the findings from the REMI model, each private practice physician in Florida is projected to support, on average: 1. 19 additional jobs 2. $913,000 in Income for those jobs 3. $2.3 million in Total Economic Activity
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The Economic Impact of Private Practice Physicians’ Offices in Florida
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F. Ov e r a l l I m pac t o f Ph ys i c i a n s by S pe c i a lt y: E m ploy m e n t ( C h a r t 5 )
Chart 5 represents the aggregate number of jobs created or maintained by private practice physicians’ offices by specialty. On average, Family Medicine specialists are projected to support around 68,000 jobs in 2009. This is followed by the offices of Internal Medicine specialists and Medical Specialties (both at 59,000 jobs), and Surgical Specialties (56,000 jobs). See Appendix G for a breakdown by specialty of jobs created or maintained by private physicians’ offices.
55,535
58,695
Medical Specialties
60,000
58,695
70,000
Internal Medicine
80,000
67,725
Chart Numberof ofJobs JobsCreated Createdoror Maintained Chart 5: Number Maintained Per Physicians' Physicians’ Offices Officesby bySpecialty Specialtyinin 2009 Per 2009
9,482
9,030
8,127
General Surgery
Neurology
Pathology
30,702 9,482
10,000
Pediatric Subspecialties
18,512
Radiology
20,000
10,385
19,866
20,769
OB/GYN
Psychiatry
23,027
30,000
Emergency Medicine
40,000
24,833
25,736
50,000
“Other”
Dermatology
Pediatrics
Anesthesiology
Surgical Specialties
Family Medicine
0
Source: FSU-CEFA REMI Analysis
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G . O v e r a l l I m p a c t o f P h y s i c i a n s b y S p e c i a l t y : T o t a l E c o n o m i c I m p a c t & Income (Chart 6)
Chart 6 compares the contributions of different medical specialties to Total Economic Impact, and Income. The contribution of different medical specialties to Total Economic Activity (referred to as “Output” in the chart) ranges from $1 billion to $8.4 billion. Finally, the contribution of different medical specialties to Income ranges from over $500 million to $4.1 billion.
Chart 6: Economic Contributions Chart 6: Economic Contributions Physicians' Offices Per Physicians’ Offices byper Specialty in 2009 by Specialty in 2009
$6.9
$7.3
8
Personal PersonalIncome Income
$7.2
Output Output
$8.4
9
7
$1.8
$3.8
$3.3 $2.3 $1.1
$2.4 $1.2
$1.2 $0.6
Pediatric Subspecialties
$1.5
$1.0 $0.5
Pathology
$1.1 $0.6
$1.2
$2.6
$3.1
$3.5
$2.9
$1.2 $0.6
1
$1.4
2
$1.3 $0.6
3
$1.6
4
$3.2
5
$3.5
$4.1
6
Other
Surgical Specialties
Radiology
Psychiatry
Pediatrics
OB/GYN
Neurology
Medical Specialties
Internal Medicine
General Surgery
Family Medicine
Emergency Medicine
Dermatology
Anesthesiology
0
Source: FSU-CEFA REMI Analysis
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H . C o u n t y - L e v e l I m p a c ts o f P h y s i c i a n s : E m p l o y m e n t & T o t a l E c o n o m i c A c t i v i t y ( C h a r ts 7 & 8 )
Although the “Top Ten” counties for economic impact by physicians are among Florida’s largest counties, the economic impact of physicians’ offices does not correspond perfectly to county population. Based on the most recent Census data, the ten most populous counties in Florida are (1) Miami-Dade, (2) Broward, (3) Palm Beach, (4) Duval, (5) Orange, (6) Pinellas, (7) Hillsborough, (8) Lee, (9) Brevard, and (10) Polk.7 Charts 7 and 8 depict the “Top Ten” counties for economic impact by physicians’ offices.
Chart 7:Supported Jobs Supported Chart 7: Jobs by Physicians' by Physicians’ Offices Offices in 2009 in 2009 60,000 50,000 40,000 30,000 20,000 10,000
Employment
0
Chart 8:Chart Contribution to Total Economic Activity 8: Contribution to Total Economic Activity by by Physicians’ Offices Physicians' Officesinin2009 2009 $7.00 $6.00 $5.00 $4.00 $3.00 $2.00 $1.00
Contribution to Total Economic Activity (in Billions)
$0.00
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I . C o m p a r i n g t h e I m p a c t o f P h y s i c i a n s ’ Off i c e s t o o t h e r K e y I n d u st r i e s i n F l o r i d a ( C h a r ts 9 & 1 0 )
The following charts provide a comparison of the economic impact of private practice physicians’ offices in Florida, relative to other key industries in the state. Unlike other components of this study, the following estimates were generated using a different econometric model, called IMPLAN, which was developed by the US Forest Service, Department of Agriculture. The data used for these estimates are from the Florida Statistical Abstract 2008, Bureau of Economic and Business Research, and from the US Department of Commerce, Bureau of Economic Analysis. Unlike other components of this study, the following estimates refer only to the direct impact of industry sectors, without taking into account the indirect and induced impacts of industry activity. Chart 9 shows that private practice physicians’ offices account for more jobs than many sectors in the state economy, including hotels, motels, casinos, amusement parks, postal service, printing, and more.
101,396
105,272
Hotels and motels (includes casinos)
234,456
57,327
41,392
Gasoline stations
50,082
39,412
23,590
8,962
50,000
1,152
100,000
Retail Stores - Electronics and appliances
150,000
Amusement parks, arcades and gambling
200,000
202,421
162,590
250,000
188,989
Chart 9: Direct Total Employment by Sectors in 2007
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Private hospitals
Retail restaurants
Retail Stores - General merchandise
Private practice physicians' offices
US Postal Service
Private colleges and universities
Printing
Boat building
Automobile manufacturing
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The Economic Impact of Private Practice Physicians’ Offices in Florida
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Chart 10 depicts that these private practice physicians’ offices account for an even greater share of Florida’s economy, in terms of their total output. In terms of direct economic activity, physicians’ offices generate more state output than all other sectors included in this analysis, with the exception of private hospitals. As noted within the literature review, physicians account for a significant portion of hospital economic activity as well.
Chart 10: Direct Total Economic Activity by Sectors (InDirect Millions, in 2009 Dollars) Chart 10: Totaland Economic Activity by Sectors (Millions of 2009 Dollars) 30,000
26,252
25,000
19,273
20,000 14,613
15,000
10,382 10,549 11,147
10,000 5,000
6,916 815
2,961 3,187 3,660 1,753 2,395 Private hospitals
Private practice physicians' offices
Amusement parks, arcades and gambling
Retail restaurants
Hotels and motels (includes casinos)
Retail Stores - General merchandise
US Postal Service
Private colleges and universities
Retail Stores - Electronics and appliances
Gasoline stations
Printing
Boat building
Automobile manufacturing
0
Interestingly, private practice physicians contribute more to Florida’s Gross State Product than the total Gross Domestic Products (GDP) of Tanzania, Bahrain or Jordan; and this contribution is approximately equal to the GDP of Jamaica and Cambodia combined.8
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Findings: The Economic Impact of Florida’s Physician Shortage A detailed analysis of the causes and consequences of Florida’s physician shortage is discussed in this report. The following two sections portray the economic impact of two aspects of Florida’s physician shortage: a lower than average ratio of physicians per population, and a lower than average ratio of Graduate Medical Education “Residency” slots per population.
A . I m p a c t o f I n c r e a s i n g F l o r i d a ’ s P h y s i c i a n - t o - P o p u l a t i o n R a t i o t o N a t i o n a l A v e r a g e ( C h a r ts 1 1 & 1 2 )
According to 2006 U.S. Census Bureau data, Florida ranks 27th in the number of physicians per 100,000 population, with 243 physicians per 100,000 population compared to 263 nationally. This means that Florida would have to increase its physician population by ten percent, or 24 doctors per 100,000 population, to meet the national average. Considering that Florida has the nation’s highest proportion of residents age 65 and over 9, Florida’s demand for healthcare services is significantly higher than other states. Florida’s below-average physician ratio signals a dramatic current and future physician shortage. If Florida increased its physician workforce by ten percent to meet the national average, these additional physicians would dramatically increase economic activity in Florida, creating jobs, and increasing Income and Total Economic Activity in the state economy. Chart 11 depicts the economic impact of these additional ten percent of physicians. Assuming that Florida reaches this goal by 2012, the model projects that the number of additional jobs created or maintained would range from over 50,000 in 2012 to almost 65,000 in 2020. In other words, if Florida fails to increase the ratio of physicians, the state will lose out on tens of thousands of jobs and the economic activity that would be associated with the increase in employment.
Chart 11: Additional Jobs Which Will Be Created with Chart 11: Additional Jobs which will be Created with National Ratio of Physicians Per 100,000 Residents National Ratio of Physicians per 100,000 Residents 70,000 60,000 50,410
52,240
54,230
56,030
57,880
59,690
61,460
63,240
64,940
50,000 40,000 30,000 20,000 10,000 0 2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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Chart 12 depicts the economic contribution of a ten percent increase in the number of physicians in Florida, in terms of Income and Total Economic Activity. The impact on Total Economic Activity ranges from $6.5 billion in 2012 to $9.3 billion in 2020. Likewise, the contribution Income ranges from over $3.6 billion in 2012 to $6.1 billion in 2020. In other words, if the workforce shortage in Florida is not addressed by 2012, the state will lose out on $6.5 billion in Total Economic Activity and $3.6 billion in Income by that year.
Chart 12: The Economic Contribution of Additional Chart 12: The Economic Contribution of Additional Physicians’ Physicians' Offices with the National Ratio of Doctors Offices with the National Ratio of Doctors per 100,000 Residents Per 100,000 Residents (In Billions, and in 2009 Dollars) (In Billions and in 2009 Dollars)
Real Disposable Personal Income Real Disp Pers Inc Output
Output
$10 $9 $8 $7
$7.1
$6.8
$6.5
$7.8
$7.5
$6.1
$6 $5 $4
$8.6
$8.2
$9.3
$8.9
$3.5
$3.8
$4.1
$4.4
$4.7
$5.1
$5.4
$5.8
$3 $2 $1 $0 2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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B . I m pac t o f E x pa n d i n g Flo r i da’ s G r a duat e M e d i c a l E du c at i o n R e s i d e n c y P r o g r a m t o t h e N a t i o n a l A v e r a g e ( C h a r ts 1 3 & 1 4 )
Florida ranks 46th nationally in the number of Graduate Medical Education (GME) “residency” positions per 100,000 population.10 The GME “residency” is required training that a medical school graduate must undertake before licensure to practice in Florida. In order to meet the national ratio of GME positions per state population, Florida would need an additional 2,700 GME positions.11 Data indicates that 60 percent of Florida’s GME “resident” physicians stay in-state after their GME residency training is complete.12 Given this assumption, if Florida increased its number of GME positions by 2,700, this would lead to additional 1,621 physicians staying in the state. Chart 13 shows that the number of jobs created or maintained due to an expansion of GME positions is estimated to be 34,000 in 2012 and near 44,000 in 2020. In other words, if Florida does not increase the ratio of GME positions by 2012, the state will lose 28,956 jobs. By 2020, this shortage will result in a loss of 37,303 jobs.
Chart 13: The Number of Jobs which will be Created Chart 13: The Number of Jobs Which Will Be Created or Maintained or Maintained with the Expansion of GME with the Expansion of GME “Residency” Program "Residency" Program 40,000 35,000 30,000
28,956
30,007
31,151
32,185
33,247
34,287
35,304
36,326
37,303
25,000 20,000 15,000 10,000 5,000 0 2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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The Economic Impact of Private Practice Physicians’ Offices in Florida
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Chart 14 depicts the impact of expanding Florida’s GME program in terms of Income and Total Economic Activity. The projected contribution to Total Economic Activity (referred to as “Output” in the chart below) ranges from $4.3 billion in 2012 to $6.3 billion in 2020. Finally, the impact of an expanded GME program on Income ranges from over $2.4 billion in 2012 to $4.1 billion in 2020. These data suggest that if Florida does not increase the number of GME positions by 2012, the state will lose $4.3 billion in Total Economic Activity, and $4.1 billion in Income.
Chart 14: Additional Economic Contributions of Physicians’ Chart 14: Additional Economic Contributions of Physicians' Offices with theofExpansion of GME Offices with the Expansion GME "Residency" Program “Residency” Program (In Billions, and in 2009 Dollars) (In Billions and in 2009 Dollars) RealDisposable Disp Pers Inc Output Real Personal Income
Output
$4.1
$6.0 $3.9
$5.8 $3.6
$5.5 $3.4
$3.0
$2.8
$2.6
$3
$2.4
$4
$3.2
$5.0
$4.8
$4.6
$4.3
$5
$5.3
$6
$6.3
$7
$2
$1
$0 2012
2013
2014
2015
2016
2017
2018
2019
2020
Source: FSU-CEFA REMI Analysis
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Trends in Florida’s Physician Practices and Physician Shortage Nationally, it is projected that the demand for physicians will exceed the supply of physicians by 2020.13 In May 2007, more than two-thirds of hospital CEOs identified a physician shortage as a serious problem that must be expediently addressed.14 The greatest shortages of physicians will be felt in specialties, including general family practice, cardiology, general surgery, ophthalmology, orthopedic surgery, urology, psychiatry, and radiology.15 The impacts of physician shortages are already apparent across the United States and even more dramatically in Florida. According to Kaiser Family Foundation and the American Academy of Family Physicians, Florida faces the third-largest physician shortage in the nation and will need 63 percent more primary care physicians within ten years to avoid a shortage in that field.16 Among the states, Florida is ranked: • 1st in the percentage of residents over age 65;17 • 2nd in the number of residents covered by Medicare;18 • 3rd in the percentage and number of uninsured;19 • 3rd in the number of paid medical malpractice claims;20 • 27th in the ratio of physicians per 100,000 population; 21 • 33rd in the ratio of primary care physicians per 100,000 population22; and • 46th in the ratio of total GME “residency” positions per 100,000 population.23 Although data varies, all sources agree that the demand for physicians outstrips the production of new doctors in Florida.24 Between 1974 and 2004, Florida’s three accredited allopathic medical schools turned out about 450 doctors per year, even as the state’s population doubled in the same period.25 Florida has 243 physicians per 100,000 population compared to an average of 267 nationwide,26 and has 106 primary care physicians per 100,000 population compared to an average of 120 nationwide.27 The economic impact of these shortages are estimated and were discussed previously in this report. To understand physician workforce shortages in Florida, the DOH workforce survey asked respondents to describe characteristics of their practice. The report found that, among physicians: • 13% indicated that they would significantly reduce or leave practice in the next 5 years; • 31% indicated that they take emergency call or work in an emergency department. Of these: • 11% have reduced their number of hours in the last two years; • 14% of OB/GYNs indicated they would discontinue deliveries in the next two years; and • 18% of radiologists who currently read breast imaging exams indicated they would decrease or discontinue performing these procedures. The impacts of a physician shortage are especially dramatic for emergency care. Between 1997 and 2006, the number of annual Emergency Department (ED) visits in Florida rose from 5.4 million to 7.4 million, and hospital admission discharges increased from 1.7 million to 2.3 million per year.28 In 2009, Florida was ranked 50th out of 51 states for “access to emergency care,” and was one of 12 states to earn an “F” rating due in part to a shortage of physicians on-call in EDs.29 These data raise important questions: Why are physicians leaving private medical practice? And what are the impacts of this on Florida’s economy?
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Factors that Contribute to Florida’s Physician Shortage There are two types of factors that contribute to the physician shortage in Florida: (1) structural factors, and (2) regulatory and policy factors. Structural factors include aspects of medical education that create and influence new doctors, while regulatory and policy factors describe the environments in which physicians treat patients and manage the business of a medical practice.
A . S t r u c t u r a l F a c t o r s
Caps on medical school enrollment At the national level, the physician shortage is in part related to previous caps on medical school enrollment, coupled with an aging population with far greater demands for healthcare services. From the late 1970s to the mid-1990s, groups such as the Institute of Medicine and the Council on Graduate Medical Education forecasted a surplus of physicians. Consequently, medical schools capped enrollment. While medical school enrollment and the number of graduates per year were basically flat from 1980 to 2005, the population of the United States grew by more than 70 million during that time.30 Shortage of residency positions in Florida A second structural factor that contributes to the physician shortage in Florida relates to Graduate Medical Education (GME) “residency” positions — the required training that a medical school graduate undertakes before licensure to practice. Florida has a shortage of GME positions, which limits the state’s ability to draw newly graduated physicians into the state. Although three new medical schools have opened in Florida in this decade, this alone does not increase the number of physicians practicing within the state. Physicians tend to remain in the state where they completed their GME training, more so than where they completed medical school. Florida ranks 46th in total GME positions per 100,000 population. In fact, only 17 percent of allopathic physicians currently practicing in Florida graduated from a Florida medical school, compared to 31 percent nationally. These statistics demonstrate that Florida cannot meet the physician workforce demand under current conditions and must import more physicians than most other states. To bring Florida at least up to the national average, the state would need an additional 2,700 GME positions.31 A shortage of GME positions means that state-funded medical schools train physicians who then leave Florida, often permanently, to attend a GME program elsewhere. The economic impact of the GME shortage was presented previously in this report. Less incentive to pursue a medical degree A final structural factor regards the incentive for students to pursue careers as physicians in the first place. Anecdotally, it is reported that guidance counselors and professors have advised “health-oriented” students to pursue other careers rather than becoming a physician. Over time, the scopes of practice for “mid-level” fields such as nursing or optometry have expanded to include many activities that are historically in the domain of physicians. These fields are portrayed to students as a faster track to careers with greater flexibility and lifestyle benefits. Physicians must attend school for longer amounts of time, incur greater debt during their training, and then must deal with running a business versus focusing their efforts solely on patient care. Over the past decade, the number of applicants to medical school has gone up and down, with a slight upward trend in the past few years. However, fewer students applied to medical school in 2008 than in 1997.32 “Scope of practice” expansions may be a contributing factor to the decrease in the number of students that wish to become physicians. For example, if a student feels he or she can perform most activities of interest as a nurse practitioner, the incentive to become a physician is lessened.
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B . R e g u l a t o r y a n d P o l i c y F a c t o r s
The degree of physician shortage varies by state and relates to the policy and regulatory environments in which physicians practice medicine. Florida’s physicians face strong challenges in the administration of private practice. These include low reimbursement rates and complicated reimbursement procedures from public assistance programs and managed care organizations, increased cost of malpractice insurance, rising premiums to provide health insurance for employees, office overhead, and more. The DOH Annual Physician Workforce Report presents factors that physicians cite as burdens on medical practice. Of the 13 percent of respondents that suggested he or she would be limiting or closing practice in the next five years, the following reasons were indicated: • • • •
Liability: 27.4%. Reimbursement: 24.4% Lifestyle considerations: 20.5% Regulatory and administrative burden: 12.1%
Similarly, in the Southwest Florida Health Care Industry Study,33 physicians rated issues that are detrimental to their practice. The highest rated were: • • • • • •
Health insurance costs: 4.3 average (on a five point scale) Other insurance costs: 4.1 average Medicare reimbursements: 3.7 average Medical malpractice: 3.6 average Uninsured or underinsured population: 3.6 average Medicaid reimbursements: 3.4 average
A 2009 small-scale exploratory survey of members of the Florida Medical Association asked physicians to rate the extent to which certain issues pose a challenge to the growth or maintenance of their practice. On a five point scale, the top rated concerns were: • • • •
Paperwork and reimbursement processes from health insurers: 4.71 average Cost of medical malpractice insurance: 4.43 average Cost of employee health insurance premiums: 4.29 average Medicaid reimbursement rates: 4.0 average
Comparatively, in this survey, costs of overhead expenses were rated as less challenging. This demonstrates the greater impact of policy concerns, relative to those of classic overhead costs: • Cost of supplies and services from vendors: 2.67 average • Cost of utilities: 3.17 average • Cost of property taxes: 3.0 average
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• Cost of property taxes: 3.0 average D i s c u ss i o n o f K e y R e g u l a t o r y F a c t o r s
Among policy or regulatory issues, concerns with liability, reimbursement, and administrative burden are perhaps the most likely to be addressed or remediated through policy and regulatory action. Each is described in brief below. Liability
Compared to the rest of the nation, Florida has a challenging malpractice environment. In 2008, Florida was ranked 50th among states on the “US Tort Liability Index,” which provides a snapshot of state business climates. Although not specific to the practice of medicine, Florida’s tort environment factors in strongly for medical practices. The Liability Index stated that in 2006, Florida’s absolute tort costs were the third highest in the nation, and that Florida’s relative tort costs (controlling for state size) were the very highest in the nation.34 Specific to physicians, Florida ranks third in the nation for total number of paid medical malpractice claims.35 In 2003, in response to skyrocketing malpractice rates, the Florida Legislature passed tort reform by placing caps on damages. Subsequently, malpractice claims in Florida have decreased: payouts and legal expenses decreased 43 percent between 2003 and 2005. However, malpractice premiums themselves have not dropped and Florida’s doctors continue to pay the highest malpractice insurance rates in the nation.36 Further, Florida still ranks third in the nation for medical malpractice payouts, both in quantity and in total dollars paid.37 An October 2005 study reported that over 54 percent of Florida physicians indicated that their delivery of certain services had been decreased or eliminated in the previous year, related to changes in the professional liability insurance market. The services most commonly eliminated were nursing home coverage, vaginal and cesarean deliveries, emergency department coverage, and mental health services. Surgical specialists and general surgeons were the most likely to decrease or eliminate services, although the trend was reported across specialties and was prevalent in both urban and rural areas of the state.38 A study by the Texas Alliance for Patient Access (TAPA) evaluated effects of sweeping malpractice reforms passed by the Texas legislature in 2003. The study found that after these reforms were passed, Texas counties had strong increases in the physician workforce, as well as greater numbers of specialists practicing in high-risk fields and emergency department settings. TAPA then estimated the economic impacts of this growth in workforce, with significant findings.39 Medicaid Reimbursement
Although physicians may opt not to participate in Medicaid, Florida’s low reimbursement rates do play a role in how physicians structure their practices, and also impact the decision of whether or not to open a practice in Florida. Currently, Florida’s Medicaid physicians receive on average 56 percent of the Medicare reimbursement rate for providing the same services. This rate does not even cover the overhead costs of the practice. For example, a primary care physician receives $27 for an office visit for a Medicaid patient, while the overhead cost of providing this service is approximately $75. The cost of providing services continues to increase, while reimbursement rates for physicians have not increased. This has resulted in a serious access to care problem for Medicaid patients, and has led many Medicaid patients to seek care in hospital emergency departments, where costs to the state are far higher than care provided in a physician’s office. There are efforts to increase Florida’s Medicaid physician rates to 100 percent of Medicare. It is suggested that this would increase the number of physicians willing to accept Medicaid patients. Indeed, a survey performed by MGT, Inc., found that the primary reason that Florida physicians decline Medicaid is low reimbursement rates and difficulty in receiving timely payment.40 A 2006 pilot program in Polk County, Florida, demonstrated the impact of increased Medicaid reimbursement on physician participation in the program by raising local Medicaid fees to 100 percent of Medicare rates. Between July 2006 and February 2007, the number of Polk County physicians participating in the Medicaid program almost doubled. Further, the county experienced a five percent decrease in Emergency Department (ED) utilization by Medicaid enrollees when comparing 2005 to 2007. This is notable, as ED utilization increased by 3.2 percent for the population as a whole during that time. Polk County’s experiment has strong implications for the impact of increasing reimbursement rates statewide.41
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A d m i n i st r a t i v e B u r d e n w i t h M a n a g e d C a r e O r g a n i z a t i o n s
Interactions with managed care organizations 42 (MCOs) have become a dominant aspect of managing a medical practice, requiring increased staff attention and creating numerous administrative burdens. Across the nation, physicians have expressed concern about the impact of MCO policies on patient care, such as restrictions on prescription formularies, limiting access to medical specialists, requiring prior approval for procedures, delaying payments to physicians, and lengthy appeals processes. Some of these dynamics can create ethical dilemmas for physicians, and may undermine patients’ trust in their physicians.43 A 1997 survey of physicians by the Kaiser Family Foundation and the Harvard School of Public Health found that 87 percent of physicians had been denied coverage for a treatment by a health plan, often resulting in what the physician considered a “potentially serious” consequence for the patient.44 Over the last few years, physicians have seen a decrease in their reimbursement from MCOs. Yet the decrease in physician revenue through payments by MCOs is not due only to reimbursement rates. MCOs have engaged in a number of business practices that make it difficult for physicians to collect fees. Such factors include: • Unfair business practices that are increasingly difficult to detect and/or identify; • A greater number of intermediary entities involved, making it difficult to trace claims; • Restrictions under Federal anti-trust laws that prevent physicians, but not MCOs, from sharing rate data or
acting collectively to address payment related issues; and • Insufficient legal safeguards or state regulatory oversight for much of this activity.
Florida has a higher managed care penetration rate than most of the states, with MCOs covering 19.4 percent of all residents, and has the third highest number of MCOs in the nation.45 Florida’s physicians have expressed a number of concerns among physicians that relate to managed care policy. As described below, these include but are not limited to: (1) the denial of payment for services that were previously authorized; (2) a lack of transparency in the rating systems used to grade physicians; and (3) difficulties with direct assignment of benefits for out-of-network physicians. (1) Denial of previously authorized claims: There are times that a physician receives a valid MCO authorization to provide treatment for a patient only to be notified after the service is rendered that the authorization was a mistake. This could be due to a patient no longer being a member of a plan, or could be due to MCO staff authorizing a treatment for which the patient did not qualify. Regardless of the cause, the physician is then held responsible to refund the MCO with no guarantee of receiving any reimbursement from the patient. If a physicians’ office receives valid authorization for a service, he or she should not be required to refund the insurer. (2) Lack of transparency in physician rating systems: Physicians across the country have also been dealing with MCO physician ranking programs. Rankings are based on claims data, practice guidelines and other factors. However, criteria used to create these rankings differ by MCO and are not made known to physicians or consumers. It is possible that a physician could receive a low rating for activities that are actually in the best interest of patients, such as a higher volume of referrals or diagnostic tests. It is important to Florida’s physicians that MCO ratings are based on valid, accurate, reliable, and most importantly, transparent data. Physicians should be made aware of rating changes and must have ways to challenge these rating decisions. (3) Direct payment and assignment of benefits: Finally, physicians in Florida are not guaranteed direct payment from insurers when they are not participants in the plan’s provider network. An “assignment of benefits” occurs when an insured patient authorizes an MCO payment to be made directly to a physician for medical services, regardless of whether the physician is a provider within the MCO’s network. Unfortunately, MCOs have been refusing to honor valid assignments of benefits by insured patients, especially to out-of-network physicians, and opt to send payments to patients rather than directly to the physician. MCOs admit to this practice, claiming that it creates incentive for physicians to participate in MCO
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networks. Of course, patients do not always submit these MCO payments to the physician, which leaves the physician without any reimbursement for services rendered and creates additional paperwork and administrative hassle for the physicians’ office. In other states, MCOs are required to honor a valid assignment of benefits, without exception. This type of requirement would benefit Florida’s physicians and patients greatly.
Previous Research on the Economic Impact of Healthcare Professionals Various studies have addressed the economic impact of the healthcare industry, ranging from a broad view of healthcare professions as a whole to specialties within medicine. The following section provides an overview of these studies. A . N ati o n w i de
While most economic impact studies target geographic regions, one study evaluated each state with a standard model, allowing a level of comparison between regions. In 2006, the Robert Graham Center, sponsored by the American Academy of Family Physicians, conducted a nationwide economic impact study that focused on family practice physicians. While this study evaluated only a sub-field of medicine, it provided a strong basis for addressing the economic impact of private practice physicians more broadly. The Graham Center study found that individual family physicians had an annual economic impact ranging from $700,000 to $1.5 million, depending on location. For example, family practice physicians in Florida were estimated at $941,000 per physician annually, with a collective impact of $3.5 billion statewide; and family practice physicians in Texas were estimated to generate $1.1 million individually or $5.4 billion statewide. According to Graham Center director Dr. Robert Philips, the study was intended to bolster efforts by family physicians to obtain financial incentives for their practices. Local governments may offer loans, tax deferments or credits, enterprise zones and other aids to small businesses; yet family practice physicians are often not included in such economic incentive programs despite their strong or greater contributions to the local economy. B. Regional
To date, the most broad regional economic impact study of private practice physicians was conducted by the Carl Vinson Institute of Government at the University of Georgia, sponsored by the Medical Association of Georgia. This study, published in October 2008, addressed the practice of medicine across specialties and across areas of the state. They found that private practice physicians accounted for 180,000 jobs, $10 billion in wages, and $20 billion in economic activity in 2008. Each individual physician was reported to support 13 additional jobs, $640,000 in personal income for those jobs, and nearly $1.5 million in Total Economic Activity. Relative to other industries, the economic impact of private practice physicians was estimated to be about half that of the state’s construction industry and nearly as large as the state’s finance and insurance industries. Further, the study estimated that by 2020, the economic impact of private practice physicians would increase, generating nearly 270,000 jobs, $17.8 billion in wages and more than $32 billion in Total Economic Activity. This study also anticipated the level of economic loss that Georgia would experience due to a physician shortage. If Georgia’s shortage of 2,500 physicians is not alleviated, the study estimated that the state would lose out on 23,000 jobs, $1.5 billion in salary, and $2.5 billion in economic activity.46 A 2008 study conducted by the Metropolitan Medical Society of Kansas City (MMSKC) also projected a physician shortage that would result in billions of dollars in economic losses. MMSKC conducted the study to raise awareness about the impact of physicians on the economy, especially as 40 percent of the area’s physicians are expected to retire within the next ten years. The study reported that the area’s 4,000 full-time physicians and 500 part-time physicians’ practices created 21,000 full-time and 3,200 part-time jobs. These practices were estimated to contribute
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$2.7 billion in payroll, spend $191 million in capital investments, spend $1 billion in operating expenses and pay $202 million in taxes annually. Finally, physicians in Kansas City were reported to provide more than $124 million in volunteer services and donate more than $19 million to local organizations.47 Also in Kansas, the Medical Society of Sedgwick County (Wichita area) conducted a study to estimate the economic impact of local hospitals, veterans’ clinics, a medical school and other healthcare facilities. They found that healthcare contributes about $2.4 billion to the county’s economy. Although this study did not look specifically at private practice physicians, it did highlight the impact of healthcare on local economies and was modeled after similar studies conducted by chambers of commerce in Jacksonville, Florida, and San Antonio, Texas.48 A report by the Mississippi State Medical Association modeled the impact of physicians on Mississippi’s county economies. They found that the increase in county economies resulting from an individual physician practice averaged $2.05 million per year, ranging from $120,000 in Tunica County to $14.24 million in Lamar County. The increased economic activity associated with a physician’s practice was estimated to support, on average, 31 jobs in the state’s county economies.49 C. Florida
Two studies have focused specifically on counties within the state of Florida, although neither does so exclusively for the impact of physicians. The first, referenced above, was conducted using 2005 data by the Center for Global Health and Medical Diplomacy at University of North Florida and addressed the economic impact of the healthcare industry, including bioscience, health insurance, and related industries, in Duval County (Jacksonville). This study found that healthcare and related industries employ one in six Jacksonville residents and are the fastest-growing segments of employment in the area. Further, the healthcare industry was found to have an economic impact of $7 billion in Jacksonville and a combined $21.7 billion impact in Northeast Florida. Within the $21.7 billion in impact, physicians were reported to account for 13.28%, or $2.8 billion per year.50,51 Blue Cross and Blue Shield of Florida, Inc., Baptist Health and Mayo Clinic are among the county’s largest employers, supporting over 20,000 jobs.52 The second county-specific study in Florida was conducted by Florida Gulf Coast University (FCGU) in 2006 for Charlotte, Collier and Lee Counties in the southwest area of the state. FGCU also included the entire health care industry when measuring impact. In terms of employment, FGCU found that the healthcare industry in Lee County was ranked second behind construction. In Charlotte County, healthcare was the largest employer, and in Collier County, healthcare ranked third behind construction, hospitality and food services. Regionally, healthcare was estimated to account for over 12 percent of total direct regional employment. The healthcare industry in these three counties created $5.1 billion of direct production, $3.3 billion of indirect production (to support the additional businesses and expenditures), summing to a total of $8.4 billion in Total Economic Activity. The main driver of this impact was hospitals, followed by physicians’ offices. Together, hospitals and physicians’ offices accounted for over half of healthcare jobs. Other sectors included in the study were nursing and residential care, pharmacies, dentists’ offices, outpatient centers, other practitioners such as chiropractors, home care, medical laboratories, ambulatory services, medical manufacturing, healthcare wholesalers, and optical stores.53 D . H o s p i t a l a n d r u r a l s e tt i n gs
Other studies have attempted to measure the economic impact of physicians within certain settings, such as within hospitals or in rural areas. A 2004 study by Merritt, Hawkins & Associates measured the average annual inpatient and outpatient revenues generated for hospitals by physicians of all specialties. They found that physicians brought an average of $1.85 million in net revenue to affiliated hospitals in 2004, an increase from $1.5 million per physician in 2002. The economic impact of certain specialties, such as orthopedic surgery, cardiology, and general
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surgery, were particularly strong.54,55 The National Center for Rural Health Works 56 suggests that revenues to hospitals from physician activity support employment and generate payroll at a rate of 12.6 jobs and $434,627 in income from patient visits. Studies that focus on rural areas have also illustrated the economic impact of physicians on the local economy. The National Center for Rural Health Professions has conducted various studies to measure the impact of health care on rural county economies. These studies suggest that the healthcare system is often one of the top employers in rural communities, in some cases, second only to local schools. For example, in a study of Illinois counties, it was estimated that healthcare generates, on average, 9.1 percent of private earnings and approximately 16.4 percent of total employment, excluding government or self-employed employees.57 The University of Minnesota estimated that for a town of 2,000, approximately $3 million will be spent on healthcare; with smaller towns experiencing a larger percentage of the economy that is involved in healthcare.58 It is suggested that rural counties have fewer employment options than urban counties and that this leads to a greater overall impact by the healthcare industry.
Research Team T h e F l o r i d a M e d i c a l Ass o c i a t i o n ( F MA ) is a professional association dedicated to the service and assistance of Doctors of Medicine and Doctors of Osteopathic Medicine in Florida. The FMA represents more than 19,000 physicians on issues of legislation and regulatory affairs, medical economics and education, public health, and ethical and legal issues. The FMA advocates for physicians and their patients to promote the public health, ensure the highest standards of medical practice, and to enhance the quality and availability of healthcare in the Sunshine State. The FMA Helps Physicians Practice Medicine. K a r e n H a l p e r i n C y p h e r s is Director of Health Care Policy at the FMA and a doctoral candidate in the Department of Political Science at Florida State University (FSU). Karen previously served as deputy policy chief in the Executive Office of the Governor, Health and Human Services Unit; deputy policy director for the Charlie Crist for Governor Campaign; Legislative Fellow in the Health and Families Council of the Florida House of Representative; and legislative staff in the Florida Senate. Karen holds a B.A. in anthropology from New College of Florida and an M.S. in political science from FSU, where she also worked as an adjunct instructor for courses in American government and politics. Karen’s doctoral studies focus on health policy, experimental methods, and state politics. T h e F l o r i da S tat e U n i v e r s i t y C e n t e r f o r E c o n o m i c I m pa c t a n d A n a ly s i s ( CE F A ) specializes in applying advanced, computer-based economic models and techniques to perform economic analyses and to examine public policy issues across a spectrum of research areas. CEFA provides advanced research and training in the areas of economic development, energy, and environmental economics, among other areas. FSU CEFA also trains students on the uses and applications of advanced economics and statistical tools. N e c a t i A y d i n , P h D , is the Senior Research Analyst at the Florida State Center for Economic Impact and
Analysis (CEFA). Dr. Aydin received his bachelor’s degree in Public Finance, master’s degree in International Economics, and doctoral degrees in both Education and Economics. Dr. Aydin is the director of the newly established Happiness Studies Program under CEFA. The program specializes in well-being studies, both at individual and societal levels, and brings experts from psychology, economics, neuroscience, sociology, anthropology, and philosophy departments to conduct qualitative and quantitative analysis. Dr. Aydin taught at Florida A & M University as an Adjunct Professor of Economics. Dr. Aydin also works for Florida TaxWatch as the Senior Research Analyst on grant proposals, conducting research on various projects.
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Appendixes Appendix A: REMI Model Appendix B: Major Economic Impacts of Private Practice Physicians in Florida Appendix C: Number of Jobs Created or Maintained by Physicians’ Offices by County Appendix E: The Contribution of Physicians’ Offices to Total Economic Activity by County Appendix F: The Contribution of Physicians’ Offices to Personal Disposable Income by County Appendix G: Total Number of Jobs Created or Maintained by Medical Specialty
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Appendix A: REMI M o d e l
Regional Economic Models, Inc. of Amherst, Massachusetts developed the REMI model in 1980. It specifies commodity-trade and personal-income flows between regions creating long-term portraits of regional economic growth. The model consists of five basic blocks as seen in the chart below: (1) output, (2) labor and capital demands, (3) population and labor supply, (4) wages, prices, and cost, and (5) market shares.
(1) OUTPUT State and Local Government Spending
Exports
Investment
(3) Population & Labor Supply Migration
(2) Labor & Capital Demand
Population
Participation Rate
Consumption
Output
Employment Optimal Capital Stock
Labor Force
Labor Output Ratio
Real Disposable Income
(5) Market Shares
Domestic Market Share
International Market Share
(4) Wages, Prices, & Cost Employment Opportunity
Housing Price
Compensation
Consumer Price Deflator
Composite Compensation Rate
Real Compensation Rate
Production Costs
Composite Prices
Source: www.remi.com
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Production is categorized into 49 non-farms, private industries (primarily at the two-digit S.I.C. level), three government sectors, and the farm sector. Economic relationships are given by an industry-based input-output component combined with an econometric component. The econometric specifications are derived from economic theories that are generally neoclassical in nature. The model is dynamic, enabling it to be used both as an impact model and for forecasting. The REMI model, as Bolton (1985) states in a review of econometric models, “is a world apart in complexity, reliance on inter-industry linkages, and modeling philosophy” from other econometric models. It may be seen as an eclectic model that links an input-output model to an econometric model. In this way, if econometric responses are suppressed, the model collapses to an input-output model. REMI uses three sources of employment and wage and salary data: (1) Bureau of Economic Analysis (BEA) employment, wage and personal income series; (2) ES202 establishment employment and wage and salary data; and (3) County Business Patterns (CBP) data published by the U.S Census Bureau. The BEA data are annual averages reported at the two-digit level for states and one-digit for counties. The ES202 data, which are the foundation for BEA data, are collected monthly in conjunction with the unemployment insurance program at the two-digit level for counties and states. CBP data are collected in conjunction with Social Security programming in March of each year. Output measures are based on regional employment data, the BEA Gross State Product series, and national outputto-employment ratios. REMI begins by applying the national output-to-employee ratio to employment by industry. This application is adjusted by regional differences in labor intensity and total factor productivity. Regional differences are given by industry production function and unit factor costs. Total factor productivity calculations depend on industry valueadded in production reported in real U.S. dollars by BEA and on adjustments by REMI to the BEA numbers. REMI is a widely used, dynamic, integrated input-output econometric model. The model’s structure incorporates inter-industry transactions and final demand feedbacks. REMI is used extensively to measure proposed legislative and other program and policy economic impacts across the private and public sectors. The Florida Legislative Office of Economic & Demographic Research, the state Agency for Workforce Innovation, and other state and local government agencies use REMI extensively to measure economic impacts of proposed legislative and policy proposals. In addition, REMI is the chosen tool to measure these impacts by a number of universities and private research groups that evaluate economic impacts across the state and nation. REMI has been widely used to model the economic impacts of property and sales tax analyses. The REMI model used for this analysis was specifically developed for the state of Florida (using the latest state data), and includes 169 sectors. In addition to accounting for economic variables (production, spending, employment), REMI also accounts for labor force, population (migration, births, deaths) and fiscal impacts.
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Appendix B: M a j o r E c o n o m i c I m p a c ts o f P r i v a t e P r a c t i c e P h y s i c i a n s in Florida (In 2009 Dollars)
Variable
2007
2008
2009
2010
2011
2012
2013
2014
414,800
435,300
451,500
468,600
486,700
504,100
522,400
542,300
Total GRP
$34.71
$36.95
$39.09
$41.20
$43.44
$45.73
$48.16
$50.81
Real Disposable Personal Income
$18.26
$20.30
$22.16
$23.82
$25.58
$27.28
$29.03
$30.86
Output
$49.73
$52.82
$55.71
$58.48
$61.49
$64.55
$67.82
$71.42
$2.25
$2.57
$2.88
$3.14
$3.42
$3.68
$3.94
$4.22
2015
2016
2017
2018
2019
2020
2021
2022
560,300
578,800
596,900
614,600
632,400
649,400
666,400
683,400
Total GRP
$53.26
$55.84
$58.48
$61.09
$63.76
$66.43
$69.14
$71.92
Real Disposable Personal Income
$32.57
$34.32
$36.05
$37.79
$39.56
$41.32
$43.12
$44.94
Output
$74.78
$78.30
$81.94
$85.55
$89.28
$93.01
$96.82
$100.73
Gov. Revenue
$4.48
$4.74
$5.00
$5.26
$5.52
$5.78
$6.03
$6.30
Variable
2023
2024
2025
2026
2027
2028
2029
2030
700,300
716,800
732,900
748,700
764,300
780,500
797,400
814,200
Total GRP
$74.74
$77.60
$80.47
$83.37
$86.30
$89.36
$92.55
$95.81
Real Disposable Personal Income
$46.79
$48.67
$50.57
$52.49
$54.46
$56.51
$58.64
$60.83
$104.72
$108.76
$112.83
$116.94
$121.11
$125.42
$130.04
$134.66
$6.56
$6.82
$7.09
$7.35
$7.62
$7.90
$8.19
$8.48
Total Employment
Gov. Revenue
Variable Total Employment
Total Employment
Output Gov. Revenue
Source: FSU-CEFA REMI Analysis
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Appendix C: N u m b e r o f J o bs C r e a t e d o r M a i n t a i n e d b y P r i v a t e P r a c t i c e P h y s i c i a n s ’ Off i c e s b y C o u n t y
2007
2008
2009
2010
2011
2012
2013
2014
414,800
435,300
451,500
468,600
486,700
504,100
522,400
542,300
Alachua
6,002
6,298
6,533
6,780
7,042
7,294
7,559
7,847
Bay
4,049
4,249
4,407
4,574
4,751
4,920
5,099
5,293
40
42
44
46
47
49
51
53
Brevard
14,137
14,836
15,388
15,971
16,587
17,180
17,804
18,482
Broward
39,637
41,596
43,144
44,778
46,508
48,170
49,919
51,821
Calhoun
15
16
17
17
18
19
19
20
Charlotte
3,690
3,873
4,017
4,169
4,330
4,485
4,648
4,825
Citrus
3,061
3,213
3,332
3,459
3,592
3,721
3,856
4,002
Clay
1,976
2,074
2,151
2,232
2,319
2,402
2,489
2,584
Collier
8,330
8,742
9,067
9,410
9,774
10,123
10,491
10,890
Columbia
833
874
907
941
977
1,012
1,049
1,089
DeSoto
120
126
131
136
141
146
152
157
35,887
37,661
39,062
40,542
42,108
43,613
45,197
46,918
9,296
9,755
10,118
10,502
10,907
11,297
11,707
12,153
Flagler
493
518
537
557
579
599
621
645
Franklin
46
48
50
52
53
55
57
60
Gadsden
43
45
47
49
50
52
54
56
Gilchrist
104
110
114
118
123
127
132
137
Gulf
51
53
55
57
59
61
64
66
Hardee
87
91
95
98
102
106
110
114
Hernando
2,888
3,031
3,144
3,263
3,389
3,510
3,637
3,776
Highlands
1,381
1,449
1,503
1,560
1,621
1,679
1,739
1,806
27,217
28,562
29,625
30,747
31,935
33,076
34,277
35,583
37
39
40
42
43
45
46
48
4,162
4,368
4,530
4,702
4,883
5,058
5,242
5,441
226
238
247
256
266
275
285
296
Lake
4,981
5,227
5,422
5,627
5,844
6,053
6,273
6,512
Lee
15,828
16,611
17,229
17,881
18,572
19,236
19,934
20,694
Florida
Bradford
Duval Escambia
Hillsborough Holmes Indian River Jackson
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Appendix C: 2007
2008
2009
2010
2011
2012
2013
2014
Leon
6,956
7,300
7,572
7,858
8,162
8,454
8,761
9,094
Levy
73
77
80
83
86
89
93
96
Madison
47
49
51
53
55
57
59
61
Manatee
7,035
7,383
7,658
7,948
8,255
8,550
8,860
9,198
Marion
7,471
7,840
8,132
8,440
8,766
9,079
9,409
9,767
Martin
3,661
3,842
3,985
4,136
4,296
4,450
4,611
4,787
46,148
48,429
50,231
52,133
54,147
56,083
58,119
60,333
Monroe
683
717
744
772
802
831
861
894
Nassau
264
277
287
298
310
321
332
345
2,711
2,845
2,951
3,062
3,181
3,294
3,414
3,544
353
370
384
399
414
429
444
461
Orange
31,241
32,785
34,005
35,293
36,656
37,967
39,345
40,844
Osceola
3,271
3,433
3,561
3,695
3,838
3,975
4,120
4,277
36,501
38,305
39,730
41,235
42,828
44,359
45,969
47,720
7,874
8,263
8,571
8,895
9,239
9,569
9,917
10,295
Pinellas
27,998
29,382
30,475
31,629
32,851
34,025
35,261
36,604
Polk
10,851
11,387
11,811
12,258
12,731
13,187
13,665
14,186
719
755
783
812
844
874
906
940
St. Johns
2,553
2,680
2,779
2,885
2,996
3,103
3,216
3,338
St. Lucie
3,272
3,433
3,561
3,696
3,839
3,976
4,120
4,277
Santa Rosa
1,105
1,160
1,203
1,249
1,297
1,343
1,392
1,445
Sarasota
9,946
10,438
10,826
11,236
11,670
12,087
12,526
13,003
Seminole
6,757
7,091
7,354
7,633
7,928
8,211
8,509
8,834
514
540
560
581
603
625
648
672
51
54
56
58
60
62
65
67
Taylor
157
165
171
177
184
191
198
205
Union
18
19
20
21
21
22
23
24
Volusia
7,978
8,372
8,684
9,013
9,361
9,696
10,048
10,430
Walton
258
270
280
291
302
313
324
337
Washington
158
166
172
178
185
192
199
207
3,140
3,295
3,418
3,547
3,684
3,816
3,954
4,105
Miami-Dade
Okaloosa Okeechobee
Palm Beach Pasco
Putnam
Sumter Suwannee
Unknown
34
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Â
2015
2016
2017
2018
2019
2020
2021
2022
560,300
578,800
596,900
614,600
632,400
649,400
666,400
683,400
Alachua
8,107
8,375
8,637
8,893
9,150
9,396
9,642
9,888
Bay
5,469
5,649
5,826
5,999
6,173
6,339
6,505
6,670
55
56
58
60
62
63
65
67
Brevard
19,096
19,726
20,343
20,946
21,553
22,133
22,712
23,291
Broward
53,541
55,308
57,038
58,729
60,430
62,055
63,679
65,304
Calhoun
21
22
22
23
24
24
25
25
Charlotte
4,985
5,149
5,310
5,468
5,626
5,777
5,929
6,080
Citrus
4,135
4,272
4,405
4,536
4,667
4,793
4,918
5,044
Clay
2,669
2,757
2,844
2,928
3,013
3,094
3,175
3,256
11,252
11,623
11,987
12,342
12,700
13,041
13,382
13,724
1,125
1,162
1,199
1,234
1,270
1,304
1,338
1,372
163
168
173
178
184
189
193
198
Duval
48,476
50,076
51,642
53,173
54,713
56,184
57,655
59,126
Escambia
12,557
12,971
13,377
13,774
14,173
14,553
14,934
15,315
Flagler
666
688
710
731
752
772
792
813
Franklin
62
64
66
68
70
71
73
75
Gadsden
58
60
62
64
66
67
69
71
Gilchrist
141
146
150
155
159
164
168
172
68
71
73
75
77
79
81
83
118
122
125
129
133
136
140
144
Hernando
3,901
4,030
4,156
4,279
4,403
4,522
4,640
4,758
Highlands
1,866
1,927
1,988
2,046
2,106
2,162
2,219
2,276
36,764
37,978
39,165
40,327
41,495
42,610
43,726
44,841
50
51
53
55
56
58
59
61
5,622
5,808
5,989
6,167
6,345
6,516
6,687
6,857
306
316
326
336
345
355
364
373
Lake
6,728
6,950
7,168
7,380
7,594
7,798
8,002
8,207
Lee
21,381
22,087
22,777
23,453
24,132
24,781
25,429
26,078
Florida
Bradford
Collier Columbia DeSoto
Gulf Hardee
Hillsborough Holmes Indian River Jackson
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
35
Appendix C: 2015
2016
2017
2018
2019
2020
2021
2022
Leon
9,396
9,706
10,010
10,307
10,605
10,890
11,175
11,460
Levy
99
103
106
109
112
115
118
121
Madison
63
65
67
69
71
73
75
77
Manatee
9,503
9,817
10,124
10,424
10,726
11,014
11,303
11,591
Marion
10,092
10,425
10,751
11,070
11,390
11,696
12,003
12,309
Martin
4,946
5,109
5,269
5,425
5,582
5,732
5,882
6,032
62,335
64,394
66,407
68,377
70,357
72,248
74,139
76,031
Monroe
923
954
984
1,013
1,042
1,070
1,098
1,126
Nassau
356
368
380
391
402
413
424
435
3,662
3,783
3,901
4,017
4,133
4,244
4,355
4,466
477
492
508
523
538
553
567
581
Orange
42,200
43,593
44,956
46,289
47,630
48,910
50,191
51,471
Osceola
4,419
4,564
4,707
4,847
4,987
5,121
5,255
5,389
Palm Beach
49,304
50,932
52,525
54,082
55,648
57,144
58,640
60,136
Pasco
10,636
10,987
11,331
11,667
12,005
12,328
12,650
12,973
Pinellas
37,819
39,068
40,289
41,484
42,685
43,833
44,980
46,128
Polk
14,657
15,141
15,614
16,077
16,543
16,987
17,432
17,877
971
1,003
1,035
1,065
1,096
1,126
1,155
1,185
St. Johns
3,449
3,563
3,674
3,783
3,893
3,998
4,102
4,207
St. Lucie
4,419
4,565
4,708
4,848
4,988
5,122
5,256
5,390
Santa Rosa
1,493
1,542
1,591
1,638
1,685
1,731
1,776
1,821
Sarasota
13,435
13,879
14,313
14,737
15,164
15,571
15,979
16,387
Seminole
9,127
9,428
9,723
10,011
10,301
10,578
10,855
11,132
695
718
740
762
784
805
826
847
69
72
74
76
78
80
83
85
Taylor
212
219
226
232
239
246
252
259
Union
25
26
26
27
28
29
29
30
Volusia
10,777
11,132
11,480
11,821
12,163
12,490
12,817
13,144
Walton
348
359
371
382
393
403
414
424
Washington
213
220
227
234
241
247
254
260
4,241
4,381
4,518
4,652
4,787
4,916
5,044
5,173
Miami-Dade
Okaloosa Okeechobee
Putnam
Sumter Suwannee
Unknown
36
Continued
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Â
2023
2024
2025
2026
2027
2028
2029
2030
Florida
700,300
716,800
732,900
748,700
764,300
780,500
797,400
814,200
Alachua
10,133
10,371
10,604
10,833
11,059
11,293
11,538
11,781
6,835
6,996
7,154
7,308
7,460
7,618
7,783
7,947
68
70
72
73
75
76
78
79
Brevard
23,867
24,430
24,978
25,517
26,048
26,601
27,177
27,749
Broward
66,919
68,495
70,034
71,544
73,034
74,582
76,197
77,803
Calhoun
26
27
27
28
28
29
30
30
Charlotte
6,230
6,377
6,520
6,661
6,800
6,944
7,094
7,244
Citrus
5,169
5,290
5,409
5,526
5,641
5,761
5,885
6,009
Clay
3,336
3,415
3,492
3,567
3,641
3,718
3,799
3,879
14,063
14,395
14,718
15,035
15,348
15,674
16,013
16,350
1,406
1,439
1,472
1,504
1,535
1,567
1,601
1,635
203
208
213
217
222
227
231
236
Duval
60,588
62,015
63,408
64,775
66,125
67,527
68,989
70,442
Escambia
15,694
16,064
16,425
16,779
17,128
17,492
17,870
18,247
Flagler
833
852
871
890
909
928
948
968
Franklin
77
79
81
82
84
86
88
89
Gadsden
73
74
76
78
79
81
83
84
Gilchrist
176
181
185
189
193
197
201
205
85
87
89
91
93
95
97
99
147
151
154
157
161
164
168
171
Hernando
4,876
4,991
5,103
5,213
5,322
5,434
5,552
5,669
Highlands
2,332
2,387
2,440
2,493
2,545
2,599
2,655
2,711
45,950
47,033
48,089
49,126
50,149
51,212
52,321
53,424
62
64
65
67
68
69
71
72
7,027
7,192
7,354
7,512
7,669
7,831
8,001
8,170
382
391
400
409
417
426
435
445
Lake
8,409
8,608
8,801
8,991
9,178
9,373
9,575
9,777
Lee
26,723
27,352
27,967
28,570
29,165
29,783
30,428
31,069
Bay Bradford
Collier Columbia DeSoto
Gulf Hardee
Hillsborough Holmes Indian River Jackson
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
37
Appendix C: 2023
2024
2025
2026
2027
2028
2029
2030
Leon
11,744
12,021
12,291
12,556
12,817
13,089
13,372
13,654
Levy
124
127
130
133
135
138
141
144
Madison
79
81
83
85
86
88
90
92
Manatee
11,878
12,157
12,431
12,699
12,963
13,238
13,524
13,809
Marion
12,613
12,910
13,200
13,485
13,766
14,058
14,362
14,665
Martin
6,182
6,327
6,469
6,609
6,746
6,889
7,039
7,187
77,911
79,747
81,538
83,296
85,031
86,834
88,714
90,583
Monroe
1,154
1,181
1,208
1,234
1,259
1,286
1,314
1,342
Nassau
445
456
466
476
486
496
507
518
4,577
4,684
4,790
4,893
4,995
5,101
5,211
5,321
596
610
624
637
650
664
678
693
Orange
52,744
53,987
55,199
56,389
57,564
58,784
60,057
61,323
Osceola
5,523
5,653
5,780
5,904
6,027
6,155
6,288
6,421
Palm Beach
61,623
63,075
64,492
65,882
67,255
68,681
70,168
71,646
Pasco
13,294
13,607
13,913
14,213
14,509
14,816
15,137
15,456
Pinellas
47,269
48,382
49,469
50,535
51,588
52,682
53,823
54,956
Polk
18,319
18,750
19,172
19,585
19,993
20,417
20,859
21,298
Putnam
1,214
1,243
1,271
1,298
1,325
1,353
1,382
1,412
St. Johns
4,311
4,413
4,512
4,609
4,705
4,805
4,909
5,012
St. Lucie
5,524
5,654
5,781
5,905
6,028
6,156
6,290
6,422
Santa Rosa
1,866
1,910
1,953
1,995
2,037
2,080
2,125
2,170
Sarasota
16,792
17,188
17,574
17,953
18,327
18,715
19,120
19,523
Seminole
11,407
11,676
11,938
12,196
12,450
12,714
12,989
13,263
868
889
909
928
947
968
989
1,009
87
89
91
93
95
97
99
101
Taylor
265
271
277
283
289
295
302
308
Union
31
32
32
33
34
34
35
36
Volusia
13,469
13,787
14,096
14,400
14,700
15,012
15,337
15,660
Walton
435
445
455
465
474
485
495
505
Washington
267
273
279
285
291
297
304
310
5,301
5,426
5,548
5,667
5,785
5,908
6,036
6,163
Miami-Dade
Okaloosa Okeechobee
Sumter Suwannee
Unknown
38
Continued
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Appendix D: T h e C o n t r i b u t i o n o f P r i v a t e P r a c t i c e P h y s i c i a n s ’ Off i c e s t o T o t a l Economic Activity by County (in 2009$)
2007
2008
2009
2010
2011
2012
2013
2014
Florida
$49.73
$52.82
$55.71
$58.48
$61.49
$64.55
$67.82
$71.42
Alachua
$0.72
$0.76
$0.81
$0.85
$0.89
$0.93
$0.98
$1.03
Bay
$0.49
$0.52
$0.54
$0.57
$0.60
$0.63
$0.66
$0.70
Bradford
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Brevard
$1.69
$1.80
$1.90
$1.99
$2.10
$2.20
$2.31
$2.43
Broward
$4.75
$5.05
$5.32
$5.59
$5.88
$6.17
$6.48
$6.82
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Charlotte
$0.44
$0.47
$0.50
$0.52
$0.55
$0.57
$0.60
$0.64
Citrus
$0.37
$0.39
$0.41
$0.43
$0.45
$0.48
$0.50
$0.53
Clay
$0.24
$0.25
$0.27
$0.28
$0.29
$0.31
$0.32
$0.34
Collier
$1.00
$1.06
$1.12
$1.17
$1.23
$1.30
$1.36
$1.43
Columbia
$0.10
$0.11
$0.11
$0.12
$0.12
$0.13
$0.14
$0.14
DeSoto
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
Duval
$4.30
$4.57
$4.82
$5.06
$5.32
$5.58
$5.87
$6.18
Escambia
$1.11
$1.18
$1.25
$1.31
$1.38
$1.45
$1.52
$1.60
Flagler
$0.06
$0.06
$0.07
$0.07
$0.07
$0.08
$0.08
$0.08
Franklin
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gadsden
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gilchrist
$0.01
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
Gulf
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hardee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
Hernando
$0.35
$0.37
$0.39
$0.41
$0.43
$0.45
$0.47
$0.50
Highlands
$0.17
$0.18
$0.19
$0.19
$0.20
$0.21
$0.23
$0.24
Hillsborough
$3.26
$3.47
$3.66
$3.84
$4.03
$4.24
$4.45
$4.69
Holmes
$0.00
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
Indian River
$0.50
$0.53
$0.56
$0.59
$0.62
$0.65
$0.68
$0.72
Jackson
$0.03
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
Lake
$0.60
$0.63
$0.67
$0.70
$0.74
$0.78
$0.81
$0.86
Lee
$1.90
$2.02
$2.13
$2.23
$2.35
$2.46
$2.59
$2.73
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
39
Appendix D:
40
Continued
2007
2008
2009
2010
2011
2012
2013
2014
Leon
$0.83
$0.89
$0.93
$0.98
$1.03
$1.08
$1.14
$1.20
Levy
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Madison
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Manatee
$0.84
$0.90
$0.94
$0.99
$1.04
$1.09
$1.15
$1.21
Marion
$0.90
$0.95
$1.00
$1.05
$1.11
$1.16
$1.22
$1.29
Martin
$0.44
$0.47
$0.49
$0.52
$0.54
$0.57
$0.60
$0.63
Miami-Dade
$5.53
$5.88
$6.20
$6.51
$6.84
$7.18
$7.54
$7.95
Monroe
$0.08
$0.09
$0.09
$0.10
$0.10
$0.11
$0.11
$0.12
Nassau
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
$0.04
$0.05
Okaloosa
$0.33
$0.35
$0.36
$0.38
$0.40
$0.42
$0.44
$0.47
Okeechobee
$0.04
$0.04
$0.05
$0.05
$0.05
$0.05
$0.06
$0.06
Orange
$3.75
$3.98
$4.20
$4.40
$4.63
$4.86
$5.11
$5.38
Osceola
$0.39
$0.42
$0.44
$0.46
$0.48
$0.51
$0.53
$0.56
Palm Beach
$4.38
$4.65
$4.90
$5.15
$5.41
$5.68
$5.97
$6.28
Pasco
$0.94
$1.00
$1.06
$1.11
$1.17
$1.23
$1.29
$1.36
Pinellas
$3.36
$3.56
$3.76
$3.95
$4.15
$4.36
$4.58
$4.82
Polk
$1.30
$1.38
$1.46
$1.53
$1.61
$1.69
$1.77
$1.87
Putnam
$0.09
$0.09
$0.10
$0.10
$0.11
$0.11
$0.12
$0.12
St. Johns
$0.31
$0.33
$0.34
$0.36
$0.38
$0.40
$0.42
$0.44
St. Lucie
$0.39
$0.42
$0.44
$0.46
$0.48
$0.51
$0.53
$0.56
Santa Rosa
$0.13
$0.14
$0.15
$0.16
$0.16
$0.17
$0.18
$0.19
Sarasota
$1.19
$1.27
$1.34
$1.40
$1.47
$1.55
$1.63
$1.71
Seminole
$0.81
$0.86
$0.91
$0.95
$1.00
$1.05
$1.10
$1.16
Sumter
$0.06
$0.07
$0.07
$0.07
$0.08
$0.08
$0.08
$0.09
Suwannee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Taylor
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
$0.03
Union
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Volusia
$0.96
$1.02
$1.07
$1.12
$1.18
$1.24
$1.30
$1.37
Walton
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
$0.04
Washington
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
$0.03
Unknown
$0.38
$0.40
$0.42
$0.44
$0.47
$0.49
$0.51
$0.54
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Â
2015
2016
2017
2018
2019
2020
2021
2022
Florida
$74.78
$78.30
$81.94
$85.55
$89.28
$93.01
$96.82
$100.73
Alachua
$1.08
$1.13
$1.19
$1.24
$1.29
$1.35
$1.40
$1.46
Bay
$0.73
$0.76
$0.80
$0.84
$0.87
$0.91
$0.95
$0.98
Bradford
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Brevard
$2.55
$2.67
$2.79
$2.92
$3.04
$3.17
$3.30
$3.43
Broward
$7.15
$7.48
$7.83
$8.17
$8.53
$8.89
$9.25
$9.63
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Charlotte
$0.67
$0.70
$0.73
$0.76
$0.79
$0.83
$0.86
$0.90
Citrus
$0.55
$0.58
$0.60
$0.63
$0.66
$0.69
$0.71
$0.74
Clay
$0.36
$0.37
$0.39
$0.41
$0.43
$0.44
$0.46
$0.48
Collier
$1.50
$1.57
$1.65
$1.72
$1.79
$1.87
$1.94
$2.02
Columbia
$0.15
$0.16
$0.16
$0.17
$0.18
$0.19
$0.19
$0.20
DeSoto
$0.02
$0.02
$0.02
$0.02
$0.03
$0.03
$0.03
$0.03
Duval
$6.47
$6.77
$7.09
$7.40
$7.72
$8.05
$8.38
$8.71
Escambia
$1.68
$1.75
$1.84
$1.92
$2.00
$2.08
$2.17
$2.26
Flagler
$0.09
$0.09
$0.10
$0.10
$0.11
$0.11
$0.12
$0.12
Franklin
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gadsden
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gilchrist
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
Gulf
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hardee
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
Hernando
$0.52
$0.55
$0.57
$0.60
$0.62
$0.65
$0.67
$0.70
Highlands
$0.25
$0.26
$0.27
$0.28
$0.30
$0.31
$0.32
$0.34
Hillsborough
$4.91
$5.14
$5.38
$5.61
$5.86
$6.10
$6.35
$6.61
Holmes
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Indian River
$0.75
$0.79
$0.82
$0.86
$0.90
$0.93
$0.97
$1.01
Jackson
$0.04
$0.04
$0.04
$0.05
$0.05
$0.05
$0.05
$0.06
Lake
$0.90
$0.94
$0.98
$1.03
$1.07
$1.12
$1.16
$1.21
Lee
$2.85
$2.99
$3.13
$3.26
$3.41
$3.55
$3.69
$3.84
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
41
Appendix D:
42
Continued
2015
2016
2017
2018
2019
2020
2021
2022
Leon
$1.25
$1.31
$1.37
$1.43
$1.50
$1.56
$1.62
$1.69
Levy
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
Madison
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Manatee
$1.27
$1.33
$1.39
$1.45
$1.51
$1.58
$1.64
$1.71
Marion
$1.35
$1.41
$1.48
$1.54
$1.61
$1.68
$1.74
$1.81
Martin
$0.66
$0.69
$0.72
$0.76
$0.79
$0.82
$0.85
$0.89
Miami-Dade
$8.32
$8.71
$9.12
$9.52
$9.93
$10.35
$10.77
$11.21
Monroe
$0.12
$0.13
$0.14
$0.14
$0.15
$0.15
$0.16
$0.17
Nassau
$0.05
$0.05
$0.05
$0.05
$0.06
$0.06
$0.06
$0.06
Okaloosa
$0.49
$0.51
$0.54
$0.56
$0.58
$0.61
$0.63
$0.66
Okeechobee
$0.06
$0.07
$0.07
$0.07
$0.08
$0.08
$0.08
$0.09
Orange
$5.63
$5.90
$6.17
$6.44
$6.72
$7.01
$7.29
$7.59
Osceola
$0.59
$0.62
$0.65
$0.67
$0.70
$0.73
$0.76
$0.79
Palm Beach
$6.58
$6.89
$7.21
$7.53
$7.86
$8.18
$8.52
$8.86
Pasco
$1.42
$1.49
$1.56
$1.62
$1.69
$1.77
$1.84
$1.91
Pinellas
$5.05
$5.29
$5.53
$5.77
$6.03
$6.28
$6.54
$6.80
Polk
$1.96
$2.05
$2.14
$2.24
$2.34
$2.43
$2.53
$2.63
Putnam
$0.13
$0.14
$0.14
$0.15
$0.15
$0.16
$0.17
$0.17
St. Johns
$0.46
$0.48
$0.50
$0.53
$0.55
$0.57
$0.60
$0.62
St. Lucie
$0.59
$0.62
$0.65
$0.67
$0.70
$0.73
$0.76
$0.79
Santa Rosa
$0.20
$0.21
$0.22
$0.23
$0.24
$0.25
$0.26
$0.27
Sarasota
$1.79
$1.88
$1.96
$2.05
$2.14
$2.23
$2.32
$2.42
Seminole
$1.22
$1.28
$1.33
$1.39
$1.45
$1.52
$1.58
$1.64
Sumter
$0.09
$0.10
$0.10
$0.11
$0.11
$0.12
$0.12
$0.12
Suwannee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Taylor
$0.03
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
Union
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Volusia
$1.44
$1.51
$1.58
$1.65
$1.72
$1.79
$1.86
$1.94
Walton
$0.05
$0.05
$0.05
$0.05
$0.06
$0.06
$0.06
$0.06
Washington
$0.03
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
Unknown
$0.57
$0.59
$0.62
$0.65
$0.68
$0.70
$0.73
$0.76
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Â
2023
2024
2025
2026
2027
2028
2029
2030
$104.72
$108.76
$112.83
$116.94
$121.11
$125.42
$130.04
$134.66
Alachua
$1.52
$1.57
$1.63
$1.69
$1.75
$1.81
$1.88
$1.95
Bay
$1.02
$1.06
$1.10
$1.14
$1.18
$1.22
$1.27
$1.31
Bradford
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Brevard
$3.57
$3.71
$3.85
$3.99
$4.13
$4.27
$4.43
$4.59
Broward
$10.01
$10.39
$10.78
$11.17
$11.57
$11.99
$12.43
$12.87
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.01
Charlotte
$0.93
$0.97
$1.00
$1.04
$1.08
$1.12
$1.16
$1.20
Citrus
$0.77
$0.80
$0.83
$0.86
$0.89
$0.93
$0.96
$0.99
Clay
$0.50
$0.52
$0.54
$0.56
$0.58
$0.60
$0.62
$0.64
Collier
$2.10
$2.18
$2.27
$2.35
$2.43
$2.52
$2.61
$2.70
Columbia
$0.21
$0.22
$0.23
$0.23
$0.24
$0.25
$0.26
$0.27
DeSoto
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
Duval
$9.06
$9.41
$9.76
$10.12
$10.48
$10.85
$11.25
$11.65
Escambia
$2.35
$2.44
$2.53
$2.62
$2.71
$2.81
$2.91
$3.02
Flagler
$0.12
$0.13
$0.13
$0.14
$0.14
$0.15
$0.15
$0.16
Franklin
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gadsden
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gilchrist
$0.03
$0.03
$0.03
$0.03
$0.03
$0.03
$0.03
$0.03
Gulf
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
Hardee
$0.02
$0.02
$0.02
$0.02
$0.03
$0.03
$0.03
$0.03
Hernando
$0.73
$0.76
$0.79
$0.81
$0.84
$0.87
$0.91
$0.94
Highlands
$0.35
$0.36
$0.38
$0.39
$0.40
$0.42
$0.43
$0.45
Hillsborough
$6.87
$7.14
$7.40
$7.67
$7.95
$8.23
$8.53
$8.84
Holmes
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Indian River
$1.05
$1.09
$1.13
$1.17
$1.22
$1.26
$1.30
$1.35
Jackson
$0.06
$0.06
$0.06
$0.06
$0.07
$0.07
$0.07
$0.07
Lake
$1.26
$1.31
$1.35
$1.40
$1.45
$1.51
$1.56
$1.62
Lee
$4.00
$4.15
$4.31
$4.46
$4.62
$4.79
$4.96
$5.14
Florida
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
43
Appendix D:
2023
2024
2025
2026
2027
2028
2029
2030
Leon
$1.76
$1.82
$1.89
$1.96
$2.03
$2.10
$2.18
$2.26
Levy
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
Madison
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
Manatee
$1.78
$1.84
$1.91
$1.98
$2.05
$2.13
$2.21
$2.28
Marion
$1.89
$1.96
$2.03
$2.11
$2.18
$2.26
$2.34
$2.43
Martin
$0.92
$0.96
$1.00
$1.03
$1.07
$1.11
$1.15
$1.19
$11.65
$12.10
$12.55
$13.01
$13.47
$13.95
$14.47
$14.98
Monroe
$0.17
$0.18
$0.19
$0.19
$0.20
$0.21
$0.21
$0.22
Nassau
$0.07
$0.07
$0.07
$0.07
$0.08
$0.08
$0.08
$0.09
Okaloosa
$0.68
$0.71
$0.74
$0.76
$0.79
$0.82
$0.85
$0.88
Okeechobee
$0.09
$0.09
$0.10
$0.10
$0.10
$0.11
$0.11
$0.11
Orange
$7.89
$8.19
$8.50
$8.81
$9.12
$9.45
$9.79
$10.14
Osceola
$0.83
$0.86
$0.89
$0.92
$0.96
$0.99
$1.03
$1.06
Palm Beach
$9.21
$9.57
$9.93
$10.29
$10.66
$11.04
$11.44
$11.85
Pasco
$1.99
$2.06
$2.14
$2.22
$2.30
$2.38
$2.47
$2.56
Pinellas
$7.07
$7.34
$7.62
$7.89
$8.17
$8.47
$8.78
$9.09
Polk
$2.74
$2.85
$2.95
$3.06
$3.17
$3.28
$3.40
$3.52
Putnam
$0.18
$0.19
$0.20
$0.20
$0.21
$0.22
$0.23
$0.23
St. Johns
$0.64
$0.67
$0.69
$0.72
$0.75
$0.77
$0.80
$0.83
St. Lucie
$0.83
$0.86
$0.89
$0.92
$0.96
$0.99
$1.03
$1.06
Santa Rosa
$0.28
$0.29
$0.30
$0.31
$0.32
$0.33
$0.35
$0.36
Sarasota
$2.51
$2.61
$2.71
$2.80
$2.90
$3.01
$3.12
$3.23
Seminole
$1.71
$1.77
$1.84
$1.90
$1.97
$2.04
$2.12
$2.19
Sumter
$0.13
$0.13
$0.14
$0.14
$0.15
$0.16
$0.16
$0.17
Suwannee
$0.01
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
Taylor
$0.04
$0.04
$0.04
$0.04
$0.05
$0.05
$0.05
$0.05
Union
$0.00
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
Volusia
$2.01
$2.09
$2.17
$2.25
$2.33
$2.41
$2.50
$2.59
Walton
$0.07
$0.07
$0.07
$0.07
$0.08
$0.08
$0.08
$0.08
Washington
$0.04
$0.04
$0.04
$0.04
$0.05
$0.05
$0.05
$0.05
Unknown
$0.79
$0.82
$0.85
$0.89
$0.92
$0.95
$0.98
$1.02
Miami-Dade
44
Continued
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Appendix E: T h e C o n t r i b u t i o n o f P r i v a t e P r a c t i c e P h y s i c i a n s ’ Off i c e s t o R e a l Personal Disposable Income by County (in 2009 Dollars)
2007
2008
2009
2010
2011
2012
2013
2014
Florida
$21.39
$24.37
$27.07
$29.72
$32.52
$35.28
$38.16
$41.20
Alachua
$0.31
$0.35
$0.39
$0.43
$0.47
$0.51
$0.55
$0.60
Bay
$0.21
$0.24
$0.26
$0.29
$0.32
$0.34
$0.37
$0.40
Bradford
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Brevard
$0.73
$0.83
$0.92
$1.01
$1.11
$1.20
$1.30
$1.40
Broward
$2.04
$2.33
$2.59
$2.84
$3.11
$3.37
$3.65
$3.94
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Charlotte
$0.19
$0.22
$0.24
$0.26
$0.29
$0.31
$0.34
$0.37
Citrus
$0.16
$0.18
$0.20
$0.22
$0.24
$0.26
$0.28
$0.30
Clay
$0.10
$0.12
$0.13
$0.14
$0.15
$0.17
$0.18
$0.20
Collier
$0.43
$0.49
$0.54
$0.60
$0.65
$0.71
$0.77
$0.83
Columbia
$0.04
$0.05
$0.05
$0.06
$0.07
$0.07
$0.08
$0.08
DeSoto
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Duval
$1.85
$2.11
$2.34
$2.57
$2.81
$3.05
$3.30
$3.56
Escambia
$0.48
$0.55
$0.61
$0.67
$0.73
$0.79
$0.86
$0.92
Flagler
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.05
$0.05
Franklin
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Gadsden
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Gilchrist
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gulf
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.01
Hardee
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hernando
$0.15
$0.17
$0.19
$0.21
$0.23
$0.25
$0.27
$0.29
Highlands
$0.07
$0.08
$0.09
$0.10
$0.11
$0.12
$0.13
$0.14
Hillsborough
$1.40
$1.60
$1.78
$1.95
$2.13
$2.31
$2.50
$2.70
Holmes
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Indian River
$0.21
$0.24
$0.27
$0.30
$0.33
$0.35
$0.38
$0.41
Jackson
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
Lake
$0.26
$0.29
$0.33
$0.36
$0.39
$0.42
$0.46
$0.49
Lee
$0.82
$0.93
$1.03
$1.13
$1.24
$1.35
$1.46
$1.57
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
45
Appendix E:
46
Continued
2007
2008
2009
2010
2011
2012
2013
2014
Leon
$0.36
$0.41
$0.45
$0.50
$0.55
$0.59
$0.64
$0.69
Levy
$0.00
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
Madison
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Manatee
$0.36
$0.41
$0.46
$0.50
$0.55
$0.60
$0.65
$0.70
Marion
$0.39
$0.44
$0.49
$0.54
$0.59
$0.64
$0.69
$0.74
Martin
$0.19
$0.22
$0.24
$0.26
$0.29
$0.31
$0.34
$0.36
Miami-Dade
$2.38
$2.71
$3.01
$3.31
$3.62
$3.93
$4.25
$4.58
Monroe
$0.04
$0.04
$0.04
$0.05
$0.05
$0.06
$0.06
$0.07
Nassau
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
Okaloosa
$0.14
$0.16
$0.18
$0.19
$0.21
$0.23
$0.25
$0.27
Okeechobee
$0.02
$0.02
$0.02
$0.03
$0.03
$0.03
$0.03
$0.04
Orange
$1.61
$1.84
$2.04
$2.24
$2.45
$2.66
$2.87
$3.10
Osceola
$0.17
$0.19
$0.21
$0.23
$0.26
$0.28
$0.30
$0.32
Palm Beach
$1.88
$2.14
$2.38
$2.62
$2.86
$3.10
$3.36
$3.63
Pasco
$0.41
$0.46
$0.51
$0.56
$0.62
$0.67
$0.72
$0.78
Pinellas
$1.44
$1.64
$1.83
$2.01
$2.20
$2.38
$2.58
$2.78
Polk
$0.56
$0.64
$0.71
$0.78
$0.85
$0.92
$1.00
$1.08
Putnam
$0.04
$0.04
$0.05
$0.05
$0.06
$0.06
$0.07
$0.07
St. Johns
$0.13
$0.15
$0.17
$0.18
$0.20
$0.22
$0.23
$0.25
St. Lucie
$0.17
$0.19
$0.21
$0.23
$0.26
$0.28
$0.30
$0.32
Santa Rosa
$0.06
$0.06
$0.07
$0.08
$0.09
$0.09
$0.10
$0.11
Sarasota
$0.51
$0.58
$0.65
$0.71
$0.78
$0.85
$0.92
$0.99
Seminole
$0.35
$0.40
$0.44
$0.48
$0.53
$0.57
$0.62
$0.67
Sumter
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.05
$0.05
Suwannee
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.01
Taylor
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
Union
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Volusia
$0.41
$0.47
$0.52
$0.57
$0.63
$0.68
$0.73
$0.79
Walton
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
Washington
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
Unknown
$0.16
$0.18
$0.20
$0.22
$0.25
$0.27
$0.29
$0.31
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Â
2015
2016
2017
2018
2019
2020
2021
2022
Florida
$44.19
$47.35
$50.62
$54.01
$57.56
$61.22
$65.07
$69.11
Alachua
$0.64
$0.69
$0.73
$0.78
$0.83
$0.89
$0.94
$1.00
Bay
$0.43
$0.46
$0.49
$0.53
$0.56
$0.60
$0.64
$0.67
Bradford
$0.00
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
Brevard
$1.51
$1.61
$1.73
$1.84
$1.96
$2.09
$2.22
$2.36
Broward
$4.22
$4.52
$4.84
$5.16
$5.50
$5.85
$6.22
$6.60
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Charlotte
$0.39
$0.42
$0.45
$0.48
$0.51
$0.54
$0.58
$0.61
Citrus
$0.33
$0.35
$0.37
$0.40
$0.42
$0.45
$0.48
$0.51
Clay
$0.21
$0.23
$0.24
$0.26
$0.27
$0.29
$0.31
$0.33
Collier
$0.89
$0.95
$1.02
$1.08
$1.16
$1.23
$1.31
$1.39
Columbia
$0.09
$0.10
$0.10
$0.11
$0.12
$0.12
$0.13
$0.14
DeSoto
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
Duval
$3.82
$4.10
$4.38
$4.67
$4.98
$5.30
$5.63
$5.98
Escambia
$0.99
$1.06
$1.13
$1.21
$1.29
$1.37
$1.46
$1.55
Flagler
$0.05
$0.06
$0.06
$0.06
$0.07
$0.07
$0.08
$0.08
Franklin
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gadsden
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gilchrist
$0.01
$0.01
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
Gulf
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hardee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hernando
$0.31
$0.33
$0.35
$0.38
$0.40
$0.43
$0.45
$0.48
Highlands
$0.15
$0.16
$0.17
$0.18
$0.19
$0.20
$0.22
$0.23
Hillsborough
$2.90
$3.11
$3.32
$3.54
$3.78
$4.02
$4.27
$4.53
Holmes
$0.00
$0.00
$0.00
$0.00
$0.01
$0.01
$0.01
$0.01
Indian River
$0.44
$0.48
$0.51
$0.54
$0.58
$0.61
$0.65
$0.69
Jackson
$0.02
$0.03
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
Lake
$0.53
$0.57
$0.61
$0.65
$0.69
$0.74
$0.78
$0.83
Lee
$1.69
$1.81
$1.93
$2.06
$2.20
$2.34
$2.48
$2.64
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
47
Appendix E:
48
Continued
2015
2016
2017
2018
2019
2020
2021
2022
Leon
$0.74
$0.79
$0.85
$0.91
$0.97
$1.03
$1.09
$1.16
Levy
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Madison
$0.00
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Manatee
$0.75
$0.80
$0.86
$0.92
$0.98
$1.04
$1.10
$1.17
Marion
$0.80
$0.85
$0.91
$0.97
$1.04
$1.10
$1.17
$1.24
Martin
$0.39
$0.42
$0.45
$0.48
$0.51
$0.54
$0.57
$0.61
Miami-Dade
$4.92
$5.27
$5.63
$6.01
$6.40
$6.81
$7.24
$7.69
Monroe
$0.07
$0.08
$0.08
$0.09
$0.09
$0.10
$0.11
$0.11
Nassau
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
Okaloosa
$0.29
$0.31
$0.33
$0.35
$0.38
$0.40
$0.43
$0.45
Okeechobee
$0.04
$0.04
$0.04
$0.05
$0.05
$0.05
$0.06
$0.06
Orange
$3.33
$3.57
$3.81
$4.07
$4.34
$4.61
$4.90
$5.21
Osceola
$0.35
$0.37
$0.40
$0.43
$0.45
$0.48
$0.51
$0.54
Palm Beach
$3.89
$4.17
$4.45
$4.75
$5.07
$5.39
$5.73
$6.08
Pasco
$0.84
$0.90
$0.96
$1.03
$1.09
$1.16
$1.24
$1.31
Pinellas
$2.98
$3.20
$3.42
$3.65
$3.89
$4.13
$4.39
$4.66
Polk
$1.16
$1.24
$1.32
$1.41
$1.51
$1.60
$1.70
$1.81
Putnam
$0.08
$0.08
$0.09
$0.09
$0.10
$0.11
$0.11
$0.12
St. Johns
$0.27
$0.29
$0.31
$0.33
$0.35
$0.38
$0.40
$0.43
St. Lucie
$0.35
$0.37
$0.40
$0.43
$0.45
$0.48
$0.51
$0.55
Santa Rosa
$0.12
$0.13
$0.13
$0.14
$0.15
$0.16
$0.17
$0.18
Sarasota
$1.06
$1.14
$1.21
$1.30
$1.38
$1.47
$1.56
$1.66
Seminole
$0.72
$0.77
$0.82
$0.88
$0.94
$1.00
$1.06
$1.13
Sumter
$0.05
$0.06
$0.06
$0.07
$0.07
$0.08
$0.08
$0.09
Suwannee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Taylor
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
Union
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Volusia
$0.85
$0.91
$0.97
$1.04
$1.11
$1.18
$1.25
$1.33
Walton
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
Washington
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
Unknown
$0.33
$0.36
$0.38
$0.41
$0.44
$0.46
$0.49
$0.52
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Â
2023
2024
2025
2026
2027
2028
2029
2030
Florida
$73.34
$77.76
$82.36
$87.18
$92.24
$97.62
$103.40
$109.40
Alachua
$1.06
$1.13
$1.19
$1.26
$1.33
$1.41
$1.50
$1.58
Bay
$0.72
$0.76
$0.80
$0.85
$0.90
$0.95
$1.01
$1.07
Bradford
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Brevard
$2.50
$2.65
$2.81
$2.97
$3.14
$3.33
$3.52
$3.73
Broward
$7.01
$7.43
$7.87
$8.33
$8.81
$9.33
$9.88
$10.45
Calhoun
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Charlotte
$0.65
$0.69
$0.73
$0.78
$0.82
$0.87
$0.92
$0.97
Citrus
$0.54
$0.57
$0.61
$0.64
$0.68
$0.72
$0.76
$0.81
Clay
$0.35
$0.37
$0.39
$0.42
$0.44
$0.47
$0.49
$0.52
Collier
$1.47
$1.56
$1.65
$1.75
$1.85
$1.96
$2.08
$2.20
Columbia
$0.15
$0.16
$0.17
$0.18
$0.19
$0.20
$0.21
$0.22
DeSoto
$0.02
$0.02
$0.02
$0.03
$0.03
$0.03
$0.03
$0.03
Duval
$6.35
$6.73
$7.13
$7.54
$7.98
$8.45
$8.95
$9.46
Escambia
$1.64
$1.74
$1.85
$1.95
$2.07
$2.19
$2.32
$2.45
Flagler
$0.09
$0.09
$0.10
$0.10
$0.11
$0.12
$0.12
$0.13
Franklin
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gadsden
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Gilchrist
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.03
$0.03
Gulf
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Hardee
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
$0.02
Hernando
$0.51
$0.54
$0.57
$0.61
$0.64
$0.68
$0.72
$0.76
Highlands
$0.24
$0.26
$0.27
$0.29
$0.31
$0.33
$0.34
$0.36
Hillsborough
$4.81
$5.10
$5.40
$5.72
$6.05
$6.41
$6.78
$7.18
Holmes
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Indian River
$0.74
$0.78
$0.83
$0.87
$0.93
$0.98
$1.04
$1.10
Jackson
$0.04
$0.04
$0.04
$0.05
$0.05
$0.05
$0.06
$0.06
Lake
$0.88
$0.93
$0.99
$1.05
$1.11
$1.17
$1.24
$1.31
Lee
$2.80
$2.97
$3.14
$3.33
$3.52
$3.73
$3.95
$4.17
www.fmaonline.org
The Economic Impact of Private Practice Physicians’ Offices in Florida
49
Appendix E:
50
Continued
2023
2024
2025
2026
2027
2028
2029
2030
Leon
$1.23
$1.30
$1.38
$1.46
$1.55
$1.64
$1.73
$1.83
Levy
$0.01
$0.01
$0.01
$0.02
$0.02
$0.02
$0.02
$0.02
Madison
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Manatee
$1.24
$1.32
$1.40
$1.48
$1.56
$1.66
$1.75
$1.86
Marion
$1.32
$1.40
$1.48
$1.57
$1.66
$1.76
$1.86
$1.97
Martin
$0.65
$0.69
$0.73
$0.77
$0.81
$0.86
$0.91
$0.97
Miami-Dade
$8.16
$8.65
$9.16
$9.70
$10.26
$10.86
$11.50
$12.17
Monroe
$0.12
$0.13
$0.14
$0.14
$0.15
$0.16
$0.17
$0.18
Nassau
$0.05
$0.05
$0.05
$0.06
$0.06
$0.06
$0.07
$0.07
Okaloosa
$0.48
$0.51
$0.54
$0.57
$0.60
$0.64
$0.68
$0.71
Okeechobee
$0.06
$0.07
$0.07
$0.07
$0.08
$0.08
$0.09
$0.09
Orange
$5.52
$5.86
$6.20
$6.57
$6.95
$7.35
$7.79
$8.24
Osceola
$0.58
$0.61
$0.65
$0.69
$0.73
$0.77
$0.82
$0.86
Palm Beach
$6.45
$6.84
$7.25
$7.67
$8.12
$8.59
$9.10
$9.63
Pasco
$1.39
$1.48
$1.56
$1.65
$1.75
$1.85
$1.96
$2.08
Pinellas
$4.95
$5.25
$5.56
$5.88
$6.23
$6.59
$6.98
$7.38
Polk
$1.92
$2.03
$2.15
$2.28
$2.41
$2.55
$2.70
$2.86
Putnam
$0.13
$0.13
$0.14
$0.15
$0.16
$0.17
$0.18
$0.19
St. Johns
$0.45
$0.48
$0.51
$0.54
$0.57
$0.60
$0.64
$0.67
St. Lucie
$0.58
$0.61
$0.65
$0.69
$0.73
$0.77
$0.82
$0.86
Santa Rosa
$0.20
$0.21
$0.22
$0.23
$0.25
$0.26
$0.28
$0.29
Sarasota
$1.76
$1.86
$1.97
$2.09
$2.21
$2.34
$2.48
$2.62
Seminole
$1.19
$1.27
$1.34
$1.42
$1.50
$1.59
$1.68
$1.78
Sumter
$0.09
$0.10
$0.10
$0.11
$0.11
$0.12
$0.13
$0.14
Suwannee
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
$0.01
Taylor
$0.03
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
Union
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Volusia
$1.41
$1.50
$1.58
$1.68
$1.77
$1.88
$1.99
$2.10
Walton
$0.05
$0.05
$0.05
$0.05
$0.06
$0.06
$0.06
$0.07
Washington
$0.03
$0.03
$0.03
$0.03
$0.04
$0.04
$0.04
$0.04
Unknown
$0.56
$0.59
$0.62
$0.66
$0.70
$0.74
$0.78
$0.83
The Economic Impact of Private Practice Physicians’ Offices in Florida
www.fmaonline.org
Appendix F: T o t a l N u m b e r o f J o bs C r e a t e d o r M a i n t a i n e d by Pr i vat e Pr ac t i c e Ph ys i c i a n s by S pe c i a lt y
2007
2008
2009
2010
2011
2012
2013
2014
414,800
435,300
451,500
468,600
486,700
504,100
522,400
542,300
Family Medicine
62,220
65,295
67,725
70,290
73,005
75,6 15
78,360
81,345
Internal Medicine
53,924
56,589
58,695
60,918
63,271
65,533
67,912
70,499
Medical Specialties
53,924
56,589
58,695
60,918
63,271
65,533
67,912
70,499
Surgical Specialties
51,020
53,542
55,535
57,638
59,864
62,004
64,255
66,703
Anesthesiology
23,644
24,812
25,736
26,710
27,742
28,734
29,777
30,911
Pediatrics
22,814
23,942
24,833
25,773
26,769
27,726
28,732
29,827
Emergency Medicine
21,155
22,200
23,027
23,899
24,822
25,709
26,642
27,657
OB/GYN
19,081
20,024
20,769
21,556
22,388
23,189
24,030
24,946
Psychiatry
18,251
19,153
19,866
20,618
21,415
22,180
22,986
23,861
Radiology
17,007
17,847
18,512
19,213
19,955
20,668
21,418
22,234
Dermatology
9,540
10,012
10,385
10,778
11,194
11,594
12,015
12,473
Pediatric Subspecialties
8,711
9,141
9,482
9,841
10,221
10,586
10,970
11,388
General Surgery
8,711
9,141
9,482
9,841
10,221
10,586
10,970
11,388
Neurology
8,296
8,706
9,030
9,372
9,734
10,082
10,448
10,846
Pathology
7,466
7,835
8,127
8,435
8,761
9,074
9,403
9,761
28,206
29,600
30,702
31,865
33,096
34,279
35,523
36,876
2015
2016
2017
2018
2019
2020
2021
2022
560,300
578,800
596,900
614,600
632,400
649,400
666,400
683,400
Family Medicine
84,045
86,820
89,535
92,190
94,860
97,410
99,960
102,510
Internal Medicine
72,839
75,244
77,597
79,898
82,212
84,422
86,632
88,842
Medical Specialties
72,839
75,244
77,597
79,898
82,212
84,422
86,632
88,842
Surgical Specialties
68,917
71,192
73,419
75,596
77,785
79,876
81,967
84,058
Anesthesiology
31,937
32,992
34,023
35,032
36,047
37,016
37,985
38,954
Pediatrics
30,817
31,834
32,830
33,803
34,782
35,717
36,652
37,587
Emergency Medicine
28,575
29,519
30,442
31,345
32,252
33,119
33,986
34,853
OB/GYN
25,774
26,625
27,457
28,272
29,090
29,872
30,654
31,436
Florida
“Other”
Florida
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The Economic Impact of Private Practice Physicians’ Offices in Florida
51
Appendix E:
2007
2008
2009
2010
2011
2012
2013
2014
Psychiatry
24,653
25,467
26,264
27,042
27,826
28,574
29,322
30,070
Radiology
22,972
23,731
24,473
25,199
25,928
26,625
27,322
28,019
Dermatology
12,887
13,312
13,729
14,136
14,545
14,936
15,327
15,718
Pediatric Subspecialties
11,766
12,155
12,535
12,907
13,280
13,637
13,994
14,351
General Surgery
11,766
12,155
12,535
12,907
13,280
13,637
13,994
14,351
Neurology
11,206
11,576
11,938
12,292
12,648
12,988
13,328
13,668
Pathology
10,085
10,418
10,744
11,063
11,383
11,689
11,995
12,301
“Other”
38,100
39,358
40,589
41,793
43,003
44,159
45,315
46,471
2023
2024
2025
2026
2027
2028
2029
2030
Florida
700,300
716,800
732,900
748,700
764,300
780,500
797,400
814,200
Family Medicine
105,045
107,520
109,935
112,305
114,645
117,075
119,610
122,130
Internal Medicine
91,039
93,184
95,277
97,331
99,359
101,465
103,662
105,846
Medical Specialties
91,039
93,184
95,277
97,331
99,359
101,465
103,662
105,846
Surgical Specialties
86,137
88,166
90,147
92,090
94,009
96,002
98,080
100,147
Anesthesiology
39,917
40,858
41,775
42,676
43,565
44,489
45,452
46,409
Pediatrics
38,517
39,424
40,310
41,179
42,037
42,928
43,857
44,781
Emergency Medicine
35,715
36,557
37,378
38,184
38,979
39,806
40,667
41,524
OB/GYN
32,214
32,973
33,713
34,440
35,158
35,903
36,680
37,453
Psychiatry
30,813
31,539
32,248
32,943
33,629
34,342
35,086
35,825
Radiology
28,712
29,389
30,049
30,697
31,336
32,001
32,693
33,382
Dermatology
16,107
16,486
16,857
17,220
17,579
17,952
18,340
18,727
Pediatric Subspecialties
14,706
15,053
15,391
15,723
16,050
16,391
16,745
17,098
General Surgery
14,706
15,053
15,391
15,723
16,050
16,391
16,745
17,098
Neurology
14,006
14,336
14,658
14,974
15,286
15,610
15,948
16,284
Pathology
12,605
12,902
13,192
13,477
13,757
14,049
14,353
14,656
“Other”
47,620
48,742
49,837
50,912
51,972
53,074
54,223
55,366
52
Continued
The Economic Impact of Private Practice Physicians’ Offices in Florida
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References & End Notes 1. Florida Department of Health. 2008 Florida Physician Workforce Annual Report. http://www.doh.state.fl.us/rw_bulletins/workforcerept08.pdf.
2. North American Industrial Classification System (NAICS), maintained by the US Bureau of the Census. http://www.census.gov/eos/www/naics/
3. State Statistical Abstract, published by University of Florida Bureau of Economic and Business Research. http://www.bebr.ufl.edu/
4. Council for Education Policy, Research and Improvement. http://www.cepri.state.fl.us/ 5. US Bureau of the Census. http://www.census.gov/compendia/statab/ranks/rank18.html 6. Florida Department of Health, Physician Workforce Report, 2008. http://www.floridashealth.com/rw_Bulletins/WorkforceRept08.pdf
7. State of Florida County Populations.
http://www.stateofflorida.com/Portal/DesktopDefault.aspx?tabid=95#27103
8. Estimates generated using IMPLAN model by the Florida State University Center for Economic Forecasting. 9. Federal Interagency Forum on Aging Related Statistics. http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Population.aspx
10. Medical Education Needs Analysis, Council for Education Policy, Research and Improvement (CEPRI), November 2004. http://www. cepri.state.fl.us/pdf/Med%20Ed%20Anal%20FINAL.pdf
11. Council for Education Policy, Research and Improvement. Data Cited by the University of Florida Health Science Center. http://www. news.health.ufl.edu/news/story.aspx?ID=4378
12. Medical Education Needs Analysis, Council for Education Policy, Research and Improvement (CEPRI), November 2004. http://www. cepri.state.fl.us/pdf/Med%20Ed%20Anal%20FINAL.pdf
13. “Physician Supply and Demand: Projections to 2020”. US Department of Health and Human Services. Health Resources and Services
Administration. Bureau of Health Professions. October 2006. ftp://ftp.hrsa.gov/bhpr/workforce/PhysicianForecastingPaperfinal.pdf. 14. Council on Physician and Nurse Supply, AMN Healthcare, May 2007. http://www.physiciannursesupply.com/Articles/council-survey-2007.pdf 15. “Physician Supply and Demand: Projections to 2020”. US Department of Health and Human Services. Health Resources and Services Administration. Bureau of Health Professions. October 2006. ftp://ftp.hrsa.gov/bhpr/workforce/PhysicianForecastingPaperfinal.pdf 16. Newspapers Look at Potential Physician Shortages in Several States [Nov 21, 2008]. http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=55700 17. Federal Interagency Forum on Aging Related Statistics. http://agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Population.aspx 18. Kaiser Family Foundation, State Health Facts. http://www.statehealthfacts.org/comparemaptable.jsp?ind=290&cat=6&sub=74&yr=63&typ=1&sort=n&o=d 19. Kaiser Family Foundation, State Health Facts. http://www.statehealthfacts.org/comparemaptable.jsp?ind=290&cat=6&sub=74&yr=63&typ=1&sort=n&o=d 20. Kaiser Family Foundation, State Health Facts. http://www.statehealthfacts.org/comparemaptable.jsp?ind=436&cat=8&sub=102&yr=18&typ=1&o=a&rgnhl=11&sort=1093 21. US Census Bureau. State Rankings – Statistical Abstract of the United States. Doctors Per 100,000 Resident Population, 2006. http:// www.census.gov/compendia/statab/ranks/rank18.html 22. America’s Health Rankings. http://www.americashealthrankings.org/2008/pcp.html 23. Council for Education Policy, Research and Improvement. http://www.cepri.state.fl.us/pdf/Med%20Ed%20Anal%20FINAL.pdf 24. Association of American Medical Colleges, presenting data from a 2005 report by the Board of Governors of the Statue University System of Florida. http://www.aamc.org/workforce/recentworkforcestudies2007.pdf 25. “Med School Mania”. Florida Trend Magazine. September 1, 2004. http://www.floridatrend.com/article.asp?aID=58888581.7189658.575965.9414725.0729636.468&aID2=44296 26. US Census Bureau. State Rankings – Statistical Abstract of the United States. Doctors Per 100,000 Resident Population, 2006. http:// www.census.gov/compendia/statab/ranks/rank18.html 27. America’s Health Rankings, Primary are Physicians. 2008. http://www.americashealthrankings.org/2008/pcp.html 28. Florida Agency for Health Care Administration. Discharge Data, 1997 – 2006, and Financial Filings, FY 1997-2006. Reported by the Florida Hospital Association in “Where have all the physicians gone?” http://scmsociety.typepad.com/scms_news/files/physicians_sept_07.ppt 29. National Report Card on the State of Emergency Medicine. 2009. American College of Emergency Physicians. http://www.emreportcard.org/ 30. Association of American Medical Colleges: http://www.aamc.org/data/facts/2008/women-count.htm 31. Council for Education Policy, Research and Improvement http://www.cepri.state.fl.us/pdf/Med%20Ed%20Anal%20FINAL.pdf 32. Association of American Medical Colleges: http://www.aamc.org/data/facts/2008/2008slr.htm
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33. Southwest Florida Health Care Industry Study. 2006. Florida Gulf Coast University. www.fgcu.edu/cob/healthcare/pdfFile.pdf
34. McQuillan, Lawrence J and Hovannes Abramyan. March 2008. “US Tort Liability Index: 2008 Report”. Pacific Research Institute. http:// liberty.pacificresearch.org/docLib/20080222_2008_US_Tort_Liability_Index_FS.pdf
35. Kaiser Family State Health Facts.
http://www.statehealthfacts.org/comparemaptable.jsp?ind=436&cat=8&sub=102&yr=18&typ=1&sort=1093&o=d&rgnhl=11
36. “Last insurance ‘fix’ hasn’t slashed rates.” March 1, 2007. By Jennifer Limberto. St. Petersburg Times. http://www.sptimes.com/2007/03/01/State/Last_insurance__fix__.shtml
37. Kaiser Family Foundation, State Health Facts.
http://www.statehealthfacts.org/comparemaptable.jsp?ind=436&cat=8&sub=102&yr=18&typ=1&o=a&rgnhl=11&sort=1093
38. Brooks, Robert G. and Nir Menachemi, et al. “Availability of physician services in Florida, revisited.” 2005. Archives of Internal Medicine. 165;2136-2141. http://archinte.ama-assn.org/cgi/content/full/165/18/2136
39. “Improving Access to Care: Growth in Physician Workforce by County, May 2003-May 2007”. Texas Alliance for Patient Access. http:// www.tapa.info/html/Improving_Access_GrowthbyCounty.html
40. Florida Medicaid Physician Fees Study. MGT, Inc. March 8, 2007.
http://www.fmaonline.org/pages/govtaffairs/files/feesstudy07.pdf
41. Independent analysis conducted by the Florida Medical Association. Data source: Florida Agency for Health Care Administration emergency department utilization data, 2005 and 2007.
42. HMOs are defined by the Kaiser Family Foundation as: “An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed structure or capitated rates. HMO enrollment includes enrollees in both traditional HMOs and HMO point-of-service (POS) plans through: group/commercial plans, Medicare, Medicaid, the Federal Employees Health Benefits Program, direct pay plans and unidentified HMO products.” 43. “A descriptive study of managed-care hassles in 26 practices.’ Sommers, Lucia, Trevor Hacker et al. March 2001. Western Journal of Medicine. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1071306 44. Kaiser Family Foundation/Harvard University School of Public Health Survey of Physicians and Nurses, 1997. Publication No. 1503; 1999. Available from the Kaiser Family Foundation, 1-800-656-4533, or http://www.kff.org 45. Kaiser Family State Health Facts. http://www.statehealthfacts.org/comparemaptable.jsp?ind=349&cat=7&sub=85&yr=71&typ=2&o=a&rgnhl=1&sort=n 46. “The Estimated Economic Impact of Private Practice Physicians’ Offices in Georgia,” Carl Vinson Institute of Government at the University of Georgia, commissioned by the Medical Association of Georgia. http://www.mag.org/pdfs/news_economic_study_102208.pdf 47. “2008 Metro Medical Economic Footprint study,” Metropolitan Medical Society of Greater Kansas City, October. Data based on 2007 fiscal year and gathered from 4,428 physicians representing 356 local practices and hospitals. http://www.ama-assn.org/amednews/2008/11/10/bil21110.htm and www.metromedkc.org 48. “A Healthier Economy: The Economic Impact of Wichita’s Healthcare and Related Industries,” Center for Economic Development and Business Research, W. Frank Barton School of Business, Wichita State University, March. Study based on U.S. Census Bureau 2005 data. http://www.ama-assn.org/amednews/2008/11/10/bil21110.htm 49. Economic Impacts of Physicians on Mississippi’s County Economies. Benjamin Blair. Journal MSMA, January 2009 – Vol. 50, No. 1. 50. “Recession hitting local hospitals.” December 16, 2008. Jacksonville Business Journal. http://www.bizjournals.com/jacksonville/stories/2008/12/15/daily14.html?t=printable 51. Northeast Florida Healthcare and Bioscience Industry, 2005 Impact. Published September 2007. Center for Global Health and Medical Diplomacy and Jacksonville Chamber of Commerce. http://www.unf.edu/brooks/center/data/EIS.pdf 52. “Job growth in Jacksonville healthcare providers masks ills.” January 2, 2009. Jacksonville Business Journal. http://www.bizjournals. com/jacksonville/stories/2009/01/05/story4.html 53. Florida Gulf Coast University, Southwest Florida Health Industry Study. http://www.fgcu.edu/cob/healthcare/pdfFile.pdf 54. Hospitals getting more revenues from primary care doctors. November 15, 2004. Internal Medicine News. Jennifer Silverman. http:// www.accessmylibrary.com/coms2/summary_0286-5440089_ITM 55. “By the numbers: Rural Doctors and Rural Economies.” University of Nebraska Medical Center. http://www.unmc.edu/Community/ruralmeded/fedstloc/by_the_numbers.htm 56. “The Economic Impact of a Rural Primary Care Physician and the Potential Health Dollars Lost to Out-Migrating Health Care Services.” National Center for Rural Health Works. http://www.ruralhealthworks.org 57. McNamara, Paul E and Martin MacDowell. 2003. “How does health care service delivery influence the economy of rural Illinois counties?” University of Illinois, National Center for Rural Health Programs. 58. Wright, G. E. 2001. The economics of rural practice. In J.P. Geyman, T.E. Norris, and L.G. Hart (Eds.), Textbook of Rural Medicine, (pp. 275-288). New York: McGraw-Hill.George Wright. Page 286. Cited on http://www.unmc.edu/Community/ruralmeded/fedstloc/cmntldr.htm
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The Economic Impact of Private Practice Physicians’ Offices
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Florida State University Center for Economic Forecasting & Analysis